This handout is for cardiogenic shock — septic-mixed (sicm + distributive overlap). Your care team identified this based on: septic shock + persistent low ci / low svo2 despite ne titration + 30 ml/kg crystalloid → mixed cs overlap.
Other reasons your team may use this plan: bedside echo during sepsis: new global lv dysfunction with ef drop ≥10 points from baseline (sicm phenotype, often reversible at 7–10d); stat troponin elevated in septic patient without primary acs pattern on ecg → type-2 demand-mismatch ischemia or sicm; sepsis source identified plus prior cad or hfref — high pretest probability of mixed septic + cardiogenic phenotype.
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 µg/kg/min IV titrate to MAP ≥65 | IV | continuous | SOAP-II first-line (PMID 20200382); SSC 2021 strong recommendation |
| dobutamine | 2.5–5 µg/kg/min IV (low-dose only) | IV | continuous | EARLY inotrope add-on when MAP target met but lactate / SvO2 indicate low CO from SICM; high-dose causes arrhythmia + ↑ MVO2 (DOREMI PMID 33704937; ACC/AHA 2022 HF Guideline) |
| vasopressin | 0.03 U/min fixed | IV | continuous | SSC 2021 + VASST (Russell NEJM 2008 PMID 18305265) — adjunct to NE; pulmonary-vascular sparing |
| hydrocortisone | 50 mg IV q6h (200 mg/d) | IV | q6h | ADRENAL 2018 (Venkatesh NEJM 2018 PMID 29347874) — faster shock resolution; APROCCHSS 2018 (Annane NEJM PMID 29490185) — mortality benefit |
| milrinone | 0.125–0.5 µg/kg/min IV (no bolus, renal adjust) | IV | continuous | Inodilator; non-inferior to dobutamine in CS (DOREMI PMID 33704937); avoid if SBP <90 (vasodilator effect) |
| vancomycin | 25–30 mg/kg IV load then 15–20 mg/kg q8–12h (renal-adjust by AUC/MIC) | IV | q8–12h | SSC 2021 strong recommendation — broad-spectrum within 1 hour of recognition |
| piperacillin-tazobactam | 4.5 g IV q6h (extended infusion if hemodynamically tolerated) | IV | q6h | SSC 2021 — broad gram-negative coverage; consider meropenem if ESBL risk |
Plan: Mixed septic + cardiogenic shock — NE + early inotrope (low-dose dobutamine) + SSC 2021 bundle + source control; AVOID over-vasoconstriction and high-dose inotropes
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Repeat echo at 7–10d to confirm SICM recovery; if persistent LV dysfunction → the four foundational heart-failure medications initiation per HFrEF pathway (PIONEER-HF cadence); ICU-acquired weakness rehab; post-sepsis syndrome surveillance
Guideline: Surviving Sepsis Campaign 2021 (Evans CCM 2021, PMID 34599691) + SCAI Cardiogenic Shock Classification 2022 (Naidu JACC 2022, PMID 35718438) + 2022 AHA/ACC/HFSA HF Guideline (Heidenreich Circulation 2022, PMID 35363499) + Sepsis-3 (Singer JAMA 2016)