A 62-year-old man with acute decompensated heart failure complicated by cardiogenic shock is admitted to the intensive care unit. He is on continuous renal replacement therapy (CRRT) via a right internal jugular central venous catheter and is intubated on assist-control ventilation. A norepinephrine infusion is titrated to maintain a mean arterial pressure (MAP) >65 mmHg. Despite escalating norepinephrine, his MAP remains 60 mmHg, and his cardiac index is 1.8 L/min/m². Current ventilator settings are FiO₂ 0.60, PEEP 8 cmH₂O, tidal volume 7 mL/kg ideal body weight, and respiratory rate 18 breaths/min, with SpO₂ 94%. Given his ongoing hemodynamic instability, which of the following ventilator adjustments is most appropriate to improve cardiac output?

A 68-year-old man is admitted to the ICU with acute decompensated heart failure complicated by cardiogenic shock. He is mechanically ventilated (PEEP 8 cmH₂O) and requires a continuous norepinephrine infusion via a central line to maintain MAP >65 mmHg. Laboratory studies reveal AKI (creatinine 3.8 mg/dL, baseline 1.2 mg/dL), BUN 85 mg/dL, and hyperkalemia (K⁺ 6.1 mEq/L). Despite optimal vasopressor support, he remains oliguric with fluid overload and worsening pulmonary edema. Which of the following is the most appropriate initial renal replacement modality for this patient?

A 65-year-old man was admitted to the ICU after an acute myocardial infarction complicated by cardiogenic shock. He is receiving invasive mechanical ventilation in assist-control mode with an FiO2 of 60%, PEEP of 12 cmH2O, and a tidal volume of 8 mL/kg ideal body weight. He is on a norepinephrine infusion at 0.1 mcg/kg/min through a central line. Despite vasopressor support, his mean arterial pressure has dropped to 58 mmHg and his cardiac output remains low. Which of the following ventilator adjustments is most appropriate to improve this patient’s hemodynamic status?

A 68-year-old man is admitted to the ICU after an acute myocardial infarction complicated by cardiogenic shock. He is intubated on assist-control ventilation and receiving norepinephrine at 0.1 mcg/kg/min plus vasopressin at 0.04 units/min to maintain a mean arterial pressure (MAP) of 65 mmHg. A central venous catheter shows a CVP of 12 mmHg, indicating adequate intravascular volume. He has developed acute kidney injury with anuria (Cr 3.8 mg/dL, BUN 85 mg/dL) and metabolic acidosis (pH 7.18, HCO₃⁻ 12 mEq/L), and continuous renal replacement therapy (CRRT) is planned. Which is the most appropriate strategy to manage his hemodynamics during CRRT initiation?

A 58-year-old man (weight 75 kg) is in the ICU for acute ST-elevation myocardial infarction complicated by cardiogenic shock. He is intubated on mechanical ventilation. Telemetry shows sinus tachycardia at 110 bpm. A norepinephrine infusion is running at 0.2 mcg/kg/min via a central venous catheter. Despite this, his mean arterial pressure is 58 mmHg, cardiac index is 1.8 L/min/m², and lactate is 4.2 mmol/L. He developed acute kidney injury requiring continuous renal replacement therapy 4 hours ago; his creatinine is 3.5 mg/dL (baseline 0.9 mg/dL). Which of the following is the most appropriate next pharmacologic intervention to optimize his hemodynamics?

A 68-year-old man with a history of severe COPD and right heart failure is admitted to the ICU for an acute exacerbation. Despite 4 hours of noninvasive ventilation, he remains in respiratory distress with an arterial blood gas showing pH 7.18, PaCO₂ 88 mmHg, and PaO₂ 75 mmHg on an FiO₂ of 0.5. His BMI is 42 kg/m², and bedside ultrasound confirms moderate ascites. The critical care team decides to initiate extracorporeal carbon dioxide removal (ECCO₂R) to avoid invasive mechanical ventilation. When preparing for ECCO₂R, which vascular access site is the most appropriate for this patient?

A 68-year-old man was admitted for acute myocardial infarction–related cardiogenic shock (AMI-CS). His ICU course was complicated by severe acute kidney injury and refractory metabolic acidosis requiring continuous renal replacement therapy (CRRT). He received norepinephrine at 0.08 mcg/kg/min and dobutamine at 5 mcg/kg/min via a central line and was on assist-control ventilation. Over the past 48 hours, his hemodynamics have stabilized, CRRT has been discontinued, and he was successfully extubated. His current vital signs are BP 110/70 mmHg, HR 88 bpm, RR 16 breaths/min, and SpO₂ 96% on 2 L nasal cannula. Labs show improving renal function (SCr 1.8 mg/dL from a peak of 4.5 mg/dL) and stable electrolytes. He is being prepared for transfer to a telemetry unit. Which of the following interventions is MOST critical at this stage to ensure a safe transition of care and prevent future adverse cardiovascular events?

A 62-year-old man with ischemic cardiomyopathy is admitted with acute myocardial infarction complicated by cardiogenic shock. He is receiving continuous renal replacement therapy for acute kidney injury. Despite a norepinephrine infusion at 0.1 µg/kg/min, his mean arterial pressure remains 58 mmHg (target >65 mmHg). His heart rate is 95 bpm, and cardiac index is 2.0 L/min/m². Which of the following adjustments is MOST appropriate to achieve the MAP target while minimizing adverse effects?

A 62-year-old, 80 kg man with chronic heart failure with reduced ejection fraction (EF 30%) is admitted to the ICU in cardiogenic shock. He has acute kidney injury (serum creatinine 3.5 mg/dL) requiring continuous renal replacement therapy and is euvolemic (central venous pressure 12 mmHg). A central venous catheter is in place. He is on norepinephrine 0.1 µg/kg/min, but his mean arterial pressure remains 60 mmHg and his cardiac index is 1.8 L/min/m². Which of the following is the most appropriate next step to improve cardiac output and systemic perfusion?

A 68-year-old man is in the ICU after an acute myocardial infarction complicated by cardiogenic shock. He is intubated on assist-control ventilation. Current hemodynamics: heart rate 110 bpm, MAP 62 mm Hg on norepinephrine 0.08 mcg/kg/min, CVP 12 mm Hg. He has severe acute kidney injury with metabolic acidosis (pH 7.18, HCO3 12 mEq/L, lactate 4.5 mmol/L) on CRRT. Which of the following interventions should be avoided in this patient’s hemodynamic management?