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cardio.cardiogenic-shock.post-cabg.v1PRODUCTION
cardio.cardiogenic-shock.post-cabg.v1

Cardiogenic shock — Post-CABG

cardiologyacuteadult
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11/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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

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CT surgery + anesthesia + TEE team activated

Patient inputs (9)

AKI common post-CPB; eGFR for drug dosing

Chest tube output trend: rising = active bleeding; sudden drop + hemodynamic decline = loculated tamponade

CVP differentiates tamponade (high CVP + equalization) vs vasoplegia (low to normal CVP)

STAT TEE for tamponade (loculated post-pericardiotomy effusion), valve dysfunction (paravalvular leak after combined CABG+valve), and global LV/RV function

New ST elevation in graft territory → graft failure (kink, embolization, anastomotic problem)

Mixed or central venous oxygen saturation marker of CO adequacy; low SvO2 + low MAP confirms low CO state

Perioperative MI threshold per 4th UDMI: troponin >10x ULN + ECG/imaging changes; helps identify graft failure

SBP <90 sustained drives shock-trigger threshold; vasoplegia presents with widely distributive picture (low SVR)

Lactate trend marks SCAI Stage C+; rising lactate after off-bypass is hallmark of low CO syndrome

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningpost_cabg_hemorrhagic_tamponade
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpost_cabg_perioperative_mi_with_graft_failure
    Post-CABG with new ST elevation in graft territory + troponin >10x ULN + new wall motion abnormality → emergent re-cath
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpost_cabg_acute_valvular_dysfunction
    Post-CABG with new severe MR, AR, or paravalvular leak after combined CABG+valve on TEE → CT surgery for re-operation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpost_cabg_biventricular_failure
    Post-CABG with biventricular failure (low LV + RV CO) refractory to inotropes → VA-ECMO
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepost_cabg_refractory_vasoplegia
    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
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Post-CABG cardiogenic shock — etiology-tailored regimen (vasoplegia vs tamponade vs graft failure vs valve vs pump)
axis: post_cabg_cs_phenotype
Selected axis "Post-CABG cardiogenic shock — etiology-tailored regimen (vasoplegia vs tamponade vs graft failure vs valve vs pump)" by default fallback (first axis)
  • norepinephrine
    first line
    alpha_beta_pressor
    0.05-0.5 mcg/kg/min IV titrate to MAP ≥65 • IV • continuous
    triggers: post_cabg_hypotension
    SOAP-II PMID 20200382 — first-line vasopressor; lower arrhythmia than dopamine
    rxcui 7512
  • vasopressin
    first line
    v1_agonist
    0.03-0.04 U/min fixed (no titration) • IV • continuous
    triggers: post_cabg_vasoplegia, pre_op_acei_or_arb_use
    V1-mediated vasoconstriction; especially effective in vasoplegia after CPB; pulmonary-sparing (Lomivorotov 2017)
    rxcui 11149
  • methylene blue
    second line
    guanylate_cyclase_inhibitor
    1-2 mg/kg IV bolus over 20 min (may repeat once at 4-6h) • IV • bolus
    triggers: refractory_vasoplegia_on_max_ne_and_vasopressin
    Inhibits NO-mediated vasodilation; effective for refractory vasoplegia post-cardiotomy (Lomivorotov 2017); contraindicated in G6PD deficiency + serotonergic agents (serotonin syndrome risk)
    rxcui 6878
  • epinephrine
    rescue
    alpha_beta_pressor_inotrope
    0.05-0.5 mcg/kg/min IV titrate • IV • continuous
    triggers: refractory_low_co_after_ne_and_dobutamine
    Dual alpha + beta effect; reserve for refractory shock per OptimaCC
    rxcui 3992
  • dobutamine
    first line
    beta1_inotrope
    2.5-10 mcg/kg/min IV • IV • continuous
    triggers: post_cabg_low_ci_lt_2_2
    Inotrope for myocardial stunning post-CPB; titrate to CI ≥2.2; DOREMI PMID 33704937
    rxcui 3616
  • milrinone
    second line
    pde3_inhibitor_inodilator
    0.125-0.5 mcg/kg/min IV (no bolus to avoid hypotension; renal-dose adjust) • IV • continuous
    triggers: post_cabg_with_pulmonary_htn, post_cabg_with_pre_op_bb
    Inodilator for RV failure or beta-blocker-dependent patients; non-inferior to dobutamine (DOREMI PMID 33704937)
    rxcui 52769

outpatient playbook — drug actions (2)

  1. 1. continue secondary prevention bundle
    rxcui 243670
    ASA 81 + atorvastatin 80 + GDMT per HF status • PO • as scheduled
    trigger: Post-CABG long-term
    AHA 2025 + 2021 Revasc
  2. 2. consider DAPT if vein graft + indication
    rxcui 321208
    ticagrelor 90 BID + ASA 81 × 12 mo • PO • BID + daily
    trigger: Vein graft + acceptable bleed risk
    POPular CABG / DACAB — DAPT may improve vein graft patency

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Hours-to-days post-CABG/valve surgery: SBP <90 + lactate ↑ + low CI on PA cath; 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiogenic shock — Post-CABG** (cardio.cardiogenic-shock.post-cabg.v1).
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **Post-CABG cardiogenic shock — etiology-tailored regimen (vasoplegia vs tamponade vs graft failure vs valve vs pump)**.
1. norepinephrine 0.05-0.5 mcg/kg/min IV titrate to MAP ≥65 IV continuous (alpha_beta_pressor, first line) — SOAP-II PMID 20200382 — first-line vasopressor; lower arrhythmia than dopamine
2. vasopressin 0.03-0.04 U/min fixed (no titration) IV continuous (v1_agonist, first line) — V1-mediated vasoconstriction; especially effective in vasoplegia after CPB; pulmonary-sparing (Lomivorotov 2017)
3. methylene blue 1-2 mg/kg IV bolus over 20 min (may repeat once at 4-6h) IV bolus (guanylate_cyclase_inhibitor, second line) — Inhibits NO-mediated vasodilation; effective for refractory vasoplegia post-cardiotomy (Lomivorotov 2017); contraindicated in G6PD deficiency + serotonergic agents (serotonin syndrome risk)
4. epinephrine 0.05-0.5 mcg/kg/min IV titrate IV continuous (alpha_beta_pressor_inotrope, rescue) — Dual alpha + beta effect; reserve for refractory shock per OptimaCC
5. dobutamine 2.5-10 mcg/kg/min IV IV continuous (beta1_inotrope, first line) — Inotrope for myocardial stunning post-CPB; titrate to CI ≥2.2; DOREMI PMID 33704937
6. milrinone 0.125-0.5 mcg/kg/min IV (no bolus to avoid hypotension; renal-dose adjust) IV continuous (pde3_inhibitor_inodilator, second line) — Inodilator for RV failure or beta-blocker-dependent patients; non-inferior to dobutamine (DOREMI PMID 33704937)

Setting playbook (outpatient) — Long-term post-CABG management: secondary prevention bundle, GDMT maintenance, AF surveillance, annual graft patency assessment if indicated
7. continue secondary prevention bundle ASA 81 + atorvastatin 80 + GDMT per HF status PO as scheduled — Post-CABG long-term (AHA 2025 + 2021 Revasc)
8. consider DAPT if vein graft + indication ticagrelor 90 BID + ASA 81 × 12 mo PO BID + daily — Vein graft + acceptable bleed risk (POPular CABG / DACAB — DAPT may improve vein graft patency)

Non-pharmacologic actions:
- Cardiac rehab maintenance
- Annual influenza + pneumococcal + COVID
- Smoking cessation maintenance

AVOID / contraindication checks:
- Methylene_blue_contraindicated_g6pd_deficiency (hemolysis risk)
- Methylene_blue_avoid_with_ssris_serotonergic (serotonin syndrome)
- Vasopressin_avoid_in_severe_pulmonary_htn (worsens PVR)
- Do_not_delay_re_exploration_for_hemorrhagic_tamponade (mortality scales with delay)
- Milrinone_renal_dose_required_egfr_lt_60
- Avoid_routine_iabp_no_mortality_benefit (IABP SHOCK II PMID 22920912; selective use only)
- Avoid_isolated_lv_mcs_if_rv_failure_dominant

Monitoring

Regimen monitoring:
- continuous arterial line BP + pa catheter for co pcwp svo2
- lactate + abg q2h until clearing
- chest tube output q1h (re-exploration threshold >200ml/h x 4h or sudden drop)
- daily tee for lv rv recovery and valve function
- serotonin syndrome screen if methylene blue + ssri
- methemoglobin q4h post methylene blue (rare paradoxical methemoglobinemia)
- cbc + coag q4h post op until stable

Setting (outpatient) monitoring:
- Annual lipid + LVEF
- Symptom-driven cath or CT angiography

Follow-up plan: GDMT initiation if persistent LV dysfunction (PIONEER-HF cadence); cardiac rehab post-CABG; sternal precautions; depression screening (high prevalence)
- Close-out criterion: GDMT + cardiac rehab + follow-up booked

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term post-CABG management: secondary prevention bundle, GDMT maintenance, AF surveillance, annual graft patency assessment if indicated

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 if HFrEF + cardio.ascvd.chronic.v1 for secondary prevention maintenance

Escalation triggers (move to higher acuity):
- Recurrent angina → urgent cath
- New HFrEF symptoms → expedite cardiology + GDMT optimization

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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 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

Citations

- 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) [PMID:34895950](https://pubmed.ncbi.nlm.nih.gov/34895950/)
- Cited evidence (PMID 35718438) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)
- Cited evidence (PMID 35363499) [PMID:35363499](https://pubmed.ncbi.nlm.nih.gov/35363499/)
- Cited evidence (PMID 20200382) [PMID:20200382](https://pubmed.ncbi.nlm.nih.gov/20200382/)
- Cited evidence (PMID 29449068) [PMID:29449068](https://pubmed.ncbi.nlm.nih.gov/29449068/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 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) — PMID:34895950
  • Cited evidence (PMID 35718438) — PMID:35718438
  • Cited evidence (PMID 35363499) — PMID:35363499
  • Cited evidence (PMID 20200382) — PMID:20200382
  • Cited evidence (PMID 29449068) — PMID:29449068