cardio.cardiogenic-shock.post-cabg.v1

Cardiogenic shock — Post-CABG

cardiologyacuteadultacuteinpatienttransitionoutpatient

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Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to post-CABG cardiogenic shock (low CO state hours-to-days after cardiac surgery). Differential: vasoplegic syndrome (~10%), perioperative MI (graft failure), acute valvular dysfunction (esp. combined CABG+valve), tamponade (loculated post-pericardiotomy hemopericardium), pump failure (myocardial stunning, baseline LV dysfunction unmasked). Workup centerpiece: STAT TEE for tamponade + valve + LV/RV function. Treatment: NE first-line per SOAP-II; vasopressin add-on for vasoplegia (esp pre-op ACE-I); methylene blue 1-2 mg/kg IV for refractory vasoplegia (CONTRAINDICATED in G6PD deficiency + SSRIs); IABP via femoral cannulation; Impella; VA-ECMO if biventricular; EMERGENT RE-EXPLORATION if hemorrhagic tamponade. Manifest pointer reuses cardio.cardiogenic-shock.core.v1 manifest. Design-brief pointer reuses parent (post-CABG-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as Phase E wave 7 variant.

Entry points (4)

history
Hours-to-days post-CABG/valve surgery: SBP <90 + lactate ↑ + low CI on PA cath
post_cardiac_surgery_low_co
imaging
Post-op TEE: pericardial collection with chamber compression OR new severe valvular dysfunction
tee_post_op_tamponade_or_valve
symptom
Rising chest tube output >200 mL/h × 4h or sudden cessation of drainage with hemodynamic deterioration (loculated tamponade)
rising_chest_tube_output
lab_abnormality
Rising lactate post-cardiotomy with low SvO2 → low CO syndrome
rising_lactate_post_cardiotomy

Required inputs (9)

sbprequired
vital • used at RED_FLAGS
SBP <90 sustained drives shock-trigger threshold; vasoplegia presents with widely distributive picture (low SVR)
cvprequired
vital • used at INITIAL_WORKUP
CVP differentiates tamponade (high CVP + equalization) vs vasoplegia (low to normal CVP)
tee_post_oprequired
imaging • used at INITIAL_WORKUP
STAT TEE for tamponade (loculated post-pericardiotomy effusion), valve dysfunction (paravalvular leak after combined CABG+valve), and global LV/RV function
ecgrequired
imaging • used at INITIAL_WORKUP
New ST elevation in graft territory → graft failure (kink, embolization, anastomotic problem)
lactaterequired
lab • used at RED_FLAGS
Lactate trend marks SCAI Stage C+; rising lactate after off-bypass is hallmark of low CO syndrome
svo2_or_scvo2required
lab • used at INITIAL_WORKUP
Mixed or central venous oxygen saturation marker of CO adequacy; low SvO2 + low MAP confirms low CO state
troponinrequired
lab • used at INITIAL_WORKUP
Perioperative MI threshold per 4th UDMI: troponin >10x ULN + ECG/imaging changes; helps identify graft failure
creatininerequired
lab • used at CONTEXT
AKI common post-CPB; eGFR for drug dosing
chest_tube_outputrequired
history • used at CONTEXT
Chest tube output trend: rising = active bleeding; sudden drop + hemodynamic decline = loculated tamponade

12-phase flow (11)

1FRAME
Post-CABG CS = differential of vasoplegia vs tamponade vs perioperative MI vs valvular dysfunction vs pump failure; cardiac surgery and CT anesthesia must be at bedside; STAT TEE is critical
inputs: sbp, lactate
advance: CT surgery + anesthesia + TEE team activated
2ENTRY
Identify primary etiology: tamponade (re-explore), vasoplegia (vasopressors + methylene blue), graft failure (re-cath), valve dysfunction (re-operate), pump failure (inotropes + MCS)
inputs: sbp, cvp
advance: Etiology hypothesis from TEE + ECG + chest tube output
3CONTEXT
Pre-op LV function, type of surgery (on-pump vs off-pump, combined CABG + valve), CPB time, cross-clamp time, intraoperative events, anticoagulation status
inputs: chest_tube_output, creatinine
advance: OR record reviewed
4RED_FLAGS
Hemorrhagic tamponade (rising chest tube output suddenly stopping + hypotension) → emergent re-exploration; massive transfusion + activate trauma protocol
inputs: sbp, cvp
actions: cardiac_tamponade
advance: Re-exploration decision made
5INITIAL_WORKUP
STAT TEE (tamponade, valve, LV/RV function); ECG (graft territory ischemia); ABG + lactate + SvO2; chest tube output trend; CXR for hemothorax
inputs: tee_post_op, ecg, lactate, svo2_or_scvo2, troponin
actions: cardiogenic_shock, panel.cardiac, panel.coag
advance: Etiology classified
6BRANCHING_WORKUP
Tamponade → emergent re-exploration; graft failure with persistent ischemia → re-cath; vasoplegia → escalate pressors + methylene blue; pump failure → inotropes + MCS
inputs: tee_post_op
actions: acs_pathway
advance: Etiology-specific intervention triggered
7RISK_STRATIFICATION
SCAI 2022 staging; STS predicted operative risk vs observed outcome; CardShock for perioperative CS
inputs: lactate
advance: Risk stratified
8TREATMENT
Norepinephrine first-line per SOAP-II; vasopressin add-on for vasoplegia (esp if pre-op ACE-I); methylene blue 1-2 mg/kg IV for refractory vasoplegia; epinephrine + dobutamine if low CI; IABP femoral if persistent low CO; Impella for LV failure; VA-ECMO if biventricular; EMERGENT RE-EXPLORATION if hemorrhagic tamponade
inputs: sbp, lactate
actions: cardiogenic_shock
advance: Pressor + inotrope + MCS strategy active and source addressed
9DISPOSITION
CT-ICU; advanced HF center transfer if persistent shock + LVEF <30 + non-recoverable
advance: Disposition assigned
10MONITORING
A-line + central line + PA catheter (typically already in place from OR); chest tube output q1h; lactate + ABG q2h; daily TEE for valve + LV/RV recovery; methylene blue serotonin syndrome screen if on SSRI
inputs: lactate
actions: panel.cardiac
advance: Monitoring cadence established
11FOLLOWUP
GDMT initiation if persistent LV dysfunction (PIONEER-HF cadence); cardiac rehab post-CABG; sternal precautions; depression screening (high prevalence)
advance: GDMT + cardiac rehab + follow-up booked