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boluses of 100 mL of normal saline until PCWP reaches 15 18 mm Hg to determine whether cardiac output and BP respond Pericardial tamponade due to hemorrhagic pericarditis (especially after thrombolytic therapy or cardiopulmonary resuscitation) or ventricular rupture should be considered and excluded by echocardiography if clinically indicated RV infarction, characterized by a normal PCWP but elevated RA pressure, can produce hypotension This is discussed below Most patients with cardiogenic shock will have moderate to severe LV systolic dysfunction, with a mean EF of 30% in the SHOCK trial If hypotension is only modest (systolic pressure > 90 mm Hg) and the PCWP is elevated, diuretics and an initial trial of nitroprusside (see above for dosing) are indicated If the BP falls, inotropic support will need to be added or substituted Such patients may also be treated with IABC This device unloads the LV during systole and increases diastolic coronary artery filling pressure It often facilitates the use of vasodilators in patients who previously did not tolerate them Dopamine is the most appropriate pressor for cardiogenic hypotension It should be initiated at a rate of 2 4 mcg/kg/min and increased at 5-minute intervals to the appropriate hemodynamic end point At low dosages (< 5 mcg/kg/min), it improves renal blood flow; at intermediate dosages (25 10 mcg/kg/min), it stimulates myocardial contractility; at higher dosages (> 8 mcg/kg/min), it is a potent 1-adrenergic agonist In general, BP and cardiac index rise, but PCWP does not fall Dopamine may be combined with nitroprusside or dobutamine (see above for dosing), or the latter may be used in its place if hypotension is not severe Milrinone has hemodynamic effects similar to those of dobutamine, but the longer duration of action precludes rapid dosage adjustment Norepinephrine (01 05 mcg/kg/min) is the usual pressor of last resort, since isoproterenol and epinephrine produce less vasoconstriction and do not increase coronary perfusion pressure (aortic diastolic pressure), but both tend to worsen the balance between myocardial oxygen delivery and utilization Patients with cardiogenic shock not due to hypovolemia have a poor prognosis, with 30-day mortality rates of 50 80% If they do not respond rapidly, IABC should be instituted Surgically implanted ventricular assist devices may be used in extreme cases Emergent cardiac catheterization and coronary angiography followed by percutaneous or surgical revascularization offer the best chance of survival, particularly in patients under 75 years of age. qr code crystal reports 2008 Crystal Reports QR - Code Generator - Generate QR Codes in .NET ...
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