Critical Care Medicine-Neurologic Disorders>>>>>Shock States
Question 7#

A 23-year-old man is transferred from another hospital with refractory cardiogenic shock and a diagnosis of fulminant viral myocarditis with an echocardiogram that demonstrated biventricular systolic dysfunction with estimated ejection fraction of 0.15. On arrival to the ICU, he has a PA catheter in place with PA pressures 54/30 mm Hg, a pulmonary capillary wedge pressure of 30 mm Hg, cardiac index 1.8 L/min/m2 , and mixed venous saturation (MVO2 ) of 40%. He has been treated with inotropic support with dobutamine up to a dose of 20 µg/kg/min and diuresis with a continuous high-dose IV furosemide infusion without improvement. His labs are significant for a lactate of 4 mmol/L and a creatinine that has increased from a baseline of 0.8 to 2.6 mg/dL. On examination, his extremities are cold and mottled.

Which of the following is the next best step in managing this patient?

A. Addition of milrinone infusion
B. Placement of a percutaneous mechanical circulatory support device
C. Initiation of a workup for a heart transplant
D. Transition from furosemide to bumetanide
E. Addition of neosynephrine infusion

Correct Answer is B

Comment:

Correct Answer: B

This patient has acute decompensated systolic heart failure and severe cardiogenic shock that has not responded to IV inotrope infusion and diuresis. There are no clear data that one inotrope is superior to another, and because the patient has failed to respond to high doses of dobutamine, it is unlikely that milrinone will have a significantly greater effect (answer A is incorrect). Similarly, although oral bioavailability of bumetanide is more reliable than that of furosemide, there is no evidence that patients with severe cardiogenic shock who have failed to respond to furosemide will have a greater response to bumetanide (answer D is incorrect). This patient does not have evidence of a low systemic vascular resistance, and addition of neosynphrine will simply increase LV afterload and therefore may worsen cardiac function and should be avoided (answer E is incorrect). Although a heart transplant may be considered in nonresolving cardiogenic shock, this patient has a potentially reversible cause of heart failure and needs immediate hemodynamic support (answer C is incorrect). The next best step is therefore initiation of percutaneous mechanical circulatory support to increase cardiac output and improve tissue perfusion (answer B is correct). There are no data to support the use of one mechanical support device over the other, and the support device should be chosen based on local expertise and availability. 

Reference:

  1. van Diepen S, Katz JN, Albert NM, et al. Contemprorary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation. 2017;136:e232-e268.