Patient handout

Cardiogenic shock — Post-CABG

PRODUCTION

1. Your condition

This handout is for cardiogenic shock — post-cabg. Your care team identified this based on: hours-to-days post-cabg/valve surgery: sbp <90 + lactate ↑ + low ci on pa cath.

Other reasons your team may use this plan: post-op tee: pericardial collection with chamber compression or new severe valvular dysfunction; rising chest tube output >200 ml/h × 4h or sudden cessation of drainage with hemodynamic deterioration (loculated tamponade); rising lactate post-cardiotomy with low svo2 → low co syndrome.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
norepinephrine	0.05-0.5 mcg/kg/min IV titrate to MAP ≥65	IV	continuous	SOAP-II PMID 20200382 — first-line vasopressor; lower arrhythmia than dopamine
vasopressin	0.03-0.04 U/min fixed (no titration)	IV	continuous	V1-mediated vasoconstriction; especially effective in vasoplegia after CPB; pulmonary-sparing (Lomivorotov 2017)
methylene blue	1-2 mg/kg IV bolus over 20 min (may repeat once at 4-6h)	IV	bolus	Inhibits NO-mediated vasodilation; effective for refractory vasoplegia post-cardiotomy (Lomivorotov 2017); contraindicated in G6PD deficiency + serotonergic agents (serotonin syndrome risk)
epinephrine	0.05-0.5 mcg/kg/min IV titrate	IV	continuous	Dual alpha + beta effect; reserve for refractory shock per OptimaCC
dobutamine	2.5-10 mcg/kg/min IV	IV	continuous	Inotrope for myocardial stunning post-CPB; titrate to CI ≥2.2; DOREMI PMID 33704937
milrinone	0.125-0.5 mcg/kg/min IV (no bolus to avoid hypotension; renal-dose adjust)	IV	continuous	Inodilator for RV failure or beta-blocker-dependent patients; non-inferior to dobutamine (DOREMI PMID 33704937)

Plan: Post-CABG cardiogenic shock — etiology-tailored regimen (vasoplegia vs tamponade vs graft failure vs valve vs pump)

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent angina → urgent cath
New HFrEF symptoms → expedite cardiology + the four foundational heart-failure medications optimization

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Post-CABG patient with rising chest tube output >200 mL/h × 4h then sudden cessation + hemodynamic deterioration + RV/RA collapse on TEE → emergent re-exploration(life-threatening)
Post-CABG with NE >0.5 mcg/kg/min + vasopressin maxed + persistent MAP <65 + low SVR (>1000 dyn·s·cm⁻⁵) → methylene blue 1-2 mg/kg IV
Post-CABG with new ST elevation in graft territory + troponin >10x ULN + new wall motion abnormality → emergent re-cath(life-threatening)
Post-CABG with new severe MR, AR, or paravalvular leak after combined CABG+valve on TEE → CT surgery for re-operation(life-threatening)
Post-CABG with biventricular failure (low LV + RV CO) refractory to inotropes → VA-ECMO(life-threatening)

5. Follow-up

the four foundational heart-failure medications initiation if persistent LV dysfunction (PIONEER-HF cadence); cardiac rehab post-CABG; sternal precautions; depression screening (high prevalence)

6. Sources

Guideline: 2021 AHA/ACC/SCAI Coronary Revascularization Guideline (Lawton JACC 2022, PMID 34895950) + SCAI 2022 CS staging (PMID 35718438) + 2022 ACC/AHA HF Guideline (PMID 35363499) + ELSO Red Book (post-cardiotomy ECMO)