MEDizzy - A 75-year-old man with a history of coronary artery disease,

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Trauma II

A 75-year-old man with a history of coronary artery disease, hypertension, and diabetes mellitus undergoes a right hemicolectomy for colon cancer. On the second postoperative day, he complains of shortness of breath and chest pain. He becomes hypotensive with depressed mental status and is immediately transferred to the intensive care unit. After intubation and placement on mechanical ventilation, an echocardiogram confirms cardiogenic shock. A central venous catheter is placed that demonstrates a central venous pressure of 18 mm Hg. Which of the following is the most appropriate initial management strategy?

ExplanationB. Cardiogenic shock is a circulatory pump failure leading to substantial reduction in cardiac output and resulting tissue hypoxia in the setting of adequate intravascular volume. Acute myocardial infarction is the most common cause of cardiogenic shock. Treatment of cardiac dysfunction includes maintenance of adequate oxygenation and judicious fluid administration to avoid fluid overload and development of cardiogenic pulmonary edema. The patient in this scenario has evidence of volume overload based on the elevated central venous pressure; therefore, further fluid administration is contraindicated. Inotropic support is indicated when profound cardiac dysfunction exists to improve cardiac contractility and cardiac output. Dobutamine and dopamine are commonly used inotropes in cardiogenic shock. Patients who are refractory to inotropes may require mechanical circulatory support with an intra-aortic balloon pump. This balloon pump increases coronary blood flow by reduction in systolic afterload and augmentation of diastolic perfusion pressure. Cardiac catheterization and heart transplantation have no role in the management of cardiogenic shock.