This handout is for cardiogenic shock — post non-cabg cardiac surgery (valve / transplant / complex). Your care team identified this based on: hours-to-days post-avr/mvr/transplant/bentall/lvad: sbp <90 + lactate ↑ + low ci on pa cath.
Other reasons your team may use this plan: post-op tee: severe paravalvular leak, valve dehiscence, prosthetic valve thrombosis, or new severe regurgitation; post-mv-repair tee: acute rv dilation + dysfunction + elevated pa pressure → pulmonary htn crisis; post-lvad tee: rv dilation + dysfunction + low lvad flows → acute rv failure unmasked.
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 vasoconstriction; pulmonary-sparing (preferred over NE in pulm HTN crisis); effective post-CPB vasoplegia (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 G6PD deficiency + serotonergic agents |
| epinephrine | 0.05-0.5 mcg/kg/min IV titrate | IV | continuous | Dual alpha + beta; reserve for refractory shock per OptimaCC; first-line in PGD per ISHLT |
| 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; renal-dose adjust) | IV | continuous | Inodilator preferred for RV failure + pulm HTN (PDE3 inhibition lowers PVR); non-inferior to dobutamine (DOREMI PMID 33704937) |
| inhaled nitric oxide | 20-40 ppm via ventilator circuit | inhaled | continuous | Selective pulmonary vasodilator without systemic hypotension; first-line for pulm HTN crisis post-MV repair; methemoglobin q4h monitoring; rebound on weaning so taper slowly |
| sildenafil | 20-40 mg q8h NG/PO | NG/PO | q8h | PDE5 inhibition prolongs cGMP-mediated pulmonary vasodilation; bridges off iNO to prevent rebound; safe with NE/vasopressin |
| epoprostenol | 1-4 ng/kg/min IV continuous, titrate up by 1-2 ng/kg/min q15-30 min | IV | continuous | IV prostacyclin for refractory pulm HTN crisis; bridges to RV-assist device; can also be inhaled (avoid systemic hypotension) |
| methylprednisolone | 500-1000 mg IV pulse for PGD; standard transplant induction per ISHLT | IV | pulse + maintenance | Pulse-dose for severe PGD per ISHLT 2024; standard induction immunosuppression per ISHLT |
Plan: Post non-CABG cardiac surgery CS — etiology-tailored regimen (pump failure / valve mechanical complication / pulm HTN crisis / RV failure post-LVAD / PGD / perioperative MI)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
the four foundational heart-failure medications initiation if persistent LV dysfunction (PIONEER-HF cadence); cardiac rehab; sternal precautions; INR management if mechanical valve; immunosuppression if transplant; depression screening; LVAD outpatient management if applicable
Guideline: 2020 ACC/AHA Valvular Heart Disease Guideline (Otto JACC 2021, PMID 33342586) + ISHLT 2024 Heart Transplant Guidelines + 2023 ISHLT MCS / LVAD Guideline + SCAI 2022 CS staging (Naidu PMID 35718438) + ELSO Red Book (post-cardiotomy ECMO)