I. Weaning and De-escalation of Intensive Therapies

Summary: Safe de-escalation hinges on integrated clinical, laboratory, and hemodynamic data confirming stable perfusion and end-organ function.

Hemodynamic Stability Criteria:

• Mean Arterial Pressure (MAP) ≥ 65 mmHg with minimal vasopressor support
• Cardiac Index > 2.2 L/min/m²
• Urine output > 0.5 mL/kg/h, lactate decreasing, mentation normalized

Inotrope Taper Protocol:

• Reduce dobutamine or milrinone by 0.5–1 µg/kg/min every 2–4 hours
• Monitor for hypotension, arrhythmias, oliguria
• If instability recurs, revert to prior dose and reassess

Vasopressor Reduction Sequence:

1. Wean vasopressin first.
2. Then, wean catecholamines (e.g., norepinephrine).
3. Decrease dose every 2–4 hours, maintaining MAP ≥ 65 mmHg.
4. Consider overlap with low-dose inotrope or oral vasodilator if needed to facilitate weaning.

Preventing Rebound Hypotension:

• Use brief vasopressor overlap or a small bolus of crystalloid.
• Transition to oral Guideline-Directed Medical Therapy (GDMT) (e.g., low-dose ACE inhibitor) prior to complete vasopressor discontinuation.

II. Transition from IV to Enteral Medications

Summary: Early enteral conversion supports ICU discharge and continuity of GDMT, provided gastrointestinal function and perfusion are adequate.

GI & Perfusion Assessment:

• Presence of active bowel sounds.
• Absence of significant abdominal distension or high-output diarrhea.
• Hemodynamic stability for at least 12–24 hours prior to conversion.

Enteral Access Considerations:

• Nasogastric (NG) tube is suitable for short-term use.
• Percutaneous endoscopic gastrostomy (PEG) tube should be considered if enteral access is anticipated for > 4 weeks.
• Avoid crushing extended-release (ER) formulations or medications with poor solubility for tube administration; consult pharmacy for alternatives.

IV-to-PO Conversion Ratios & Monitoring:

Adequacy of Absorption:

• Monitor blood pressure, heart rate, and diuretic response (urine output) 2–4 hours after the initial oral dose.
• Consider overlapping IV therapy for approximately 24 hours for drugs with a delayed onset of action or if absorption is uncertain.

III. Pharmacotherapy Optimization

Optimizing pharmacotherapy involves initiating and titrating Guideline-Directed Medical Therapy (GDMT) and managing anticoagulation for mechanical support devices.

A. Guideline-Directed Medical Therapy (GDMT)

1. Sacubitril/Valsartan (ARNI)

• Mechanism: Neprilysin inhibition (sacubitril) enhances beneficial natriuretic peptides, while valsartan blocks the renin-angiotensin-aldosterone system.
• Indication: HFrEF (LVEF ≤ 40%) in stabilized patients, typically after a 36-hour washout period from ACE inhibitors.
• Dosing: Start with 24/26 mg or 49/51 mg BID. Titrate every 2–4 weeks as tolerated towards the target dose of 97/103 mg BID.
• Monitoring: Blood pressure, renal function (serum creatinine), potassium levels.
• Contraindications: History of angioedema (especially related to ACEi/ARB), pregnancy, severe hepatic impairment, concomitant ACE inhibitor use.

2. Beta-Blockers

• Mechanism: Blockade of β₁ and/or β₂ adrenergic receptors reduces heart rate, myocardial contractility, and oxygen demand, leading to improved LV function over time.
• Indication: Clinically stable, euvolemic HFrEF patients who have been off IV inotropes for at least 24–48 hours.
• Agents & Dosing (initiation, then titrate by doubling dose q2 weeks as tolerated):
  • Carvedilol: Start 3.125 mg BID.
  • Metoprolol Succinate (extended-release): Start 12.5 mg or 25 mg QAM.
  • Bisoprolol: Start 1.25 mg QAM.
• Monitoring: Heart rate, blood pressure, signs of worsening congestion or fatigue.
• Contraindications: Symptomatic bradycardia, advanced AV block (without pacemaker), acute decompensated HF, severe bronchospastic disease (for non-selective agents).

3. SGLT2 Inhibitors

• Mechanism: Sodium-glucose cotransporter 2 inhibition in the proximal renal tubules leads to glucosuria, natriuresis, and osmotic diuresis. Also possess direct cardioprotective effects.
• Indication: HFrEF, regardless of diabetes status.
• Dosing: Dapagliflozin 10 mg QD or Empagliflozin 10 mg QD.
• Monitoring: Renal function (eGFR), volume status, signs of genitourinary infections.
• Contraindications: Type 1 diabetes mellitus (risk of DKA), history of recurrent genitourinary infections (use with caution), dialysis-dependent kidney disease (check specific agent labeling).

4. Mineralocorticoid Receptor Antagonists (MRAs)

• Mechanism: Blockade of aldosterone receptors, reducing sodium retention, myocardial fibrosis, and potassium/magnesium loss.
• Indication: NYHA Class II–IV HFrEF, post-stabilization.
• Dosing: Spironolactone 12.5–25 mg QD or Eplerenone 25 mg QD. Titrate to 25-50 mg QD as tolerated.
• Monitoring: Potassium levels and renal function at baseline, 3 days, 1 week after initiation/titration, and periodically thereafter.
• Contraindications: Hyperkalemia (K⁺ > 5.0 mEq/L), severe renal impairment (eGFR < 30 mL/min/1.73 m²), Addison's disease.

5. Statins

• Mechanism: HMG-CoA reductase inhibition, reducing cholesterol synthesis and pleiotropic anti-inflammatory effects.
• Indication: Primarily for atherosclerotic cardiovascular disease (ASCVD) risk reduction, particularly in patients with ischemic cardiomyopathy.
• Dosing: Moderate to high-intensity statin therapy (e.g., Atorvastatin 40–80 mg QD or Rosuvastatin 20–40 mg QD).
• Monitoring: Liver function tests (LFTs) at baseline and as clinically indicated, creatine kinase (CK) if myopathy symptoms occur.
• Contraindications: Active liver disease, unexplained persistent LFT elevations, pregnancy.

B. Device-Related Anticoagulation

• Impella: Unfractionated heparin (UFH) infusion to maintain Activated Clotting Time (ACT) typically between 160–180 seconds (institutional protocols may vary).
• VA-ECMO: UFH infusion, targeting an activated Partial Thromboplastin Time (aPTT) of 60–80 seconds or anti-Xa levels as per institutional protocol.
• Intra-Aortic Balloon Pump (IABP): Prophylactic dose UFH is often used unless a therapeutic indication for anticoagulation exists. Monitor platelet counts for heparin-induced thrombocytopenia (HIT).

C. Pharmacokinetic/Pharmacodynamic (PK/PD) & Decision Points

• Critical illness significantly alters drug absorption, distribution, metabolism, and excretion.
• Adjust medication doses based on renal and hepatic function (e.g., reduce MRA or SGLT2i doses in renal impairment).
• Be vigilant for drug-drug interactions, particularly those involving QT prolongation, potassium homeostasis (e.g., ARNI + potassium-sparing diuretics), or cytochrome P450 metabolism.

IV. Mitigation of Post-ICU Syndrome (PICS)

Summary: Early identification of at-risk patients and implementation of multidisciplinary interventions, such as the ABCDEF bundle, are crucial to reduce the morbidity associated with Post-ICU Syndrome.

Risk Stratification for PICS:

• Pre-existing frailty (e.g., Clinical Frailty Scale ≥ 5).
• History of delirium or prolonged delirium during ICU stay.
• ICU length of stay (LOS) > 7 days.
• Severity of illness, mechanical ventilation duration.

ABCDEF Bundle Implementation:

• A
  Assess, Prevent, and Manage Pain: Regular pain assessment using validated scales, multimodal analgesia.
• B
  Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs): Daily interruption of sedation and assessment for extubation readiness.
• C
  Choice of Analgesia and Sedation: Prioritize non-benzodiazepine sedatives; use lightest effective sedation.
• D
  Delirium: Assess, Prevent, and Manage: Routine delirium screening (e.g., CAM-ICU), non-pharmacological prevention strategies.
• E
  Early Mobility and Exercise: Progressive mobilization starting from day 1 of ICU admission, coordinated with physical and occupational therapy.
• F
  Family Engagement and Empowerment: Involve family in care, provide education, and support shared decision-making.

Early Mobilization Strategies:

• Progress from passive range of motion exercises to active exercises, sitting, standing, and ambulation as tolerated.
• Coordinate closely with physical therapy (PT) and occupational therapy (OT) to ensure safety and tailor activities to patient capabilities.

Multidisciplinary Coordination:

• Involve a team including physicians, nurses, pharmacists, PT, OT, speech-language pathology, psychology, nutritionists, and social workers.
• Regular team rounds to discuss PICS risk and mitigation strategies.

V. Medication Reconciliation & Discharge Counseling

Summary: A structured medication reconciliation process and comprehensive patient education are vital to prevent medication errors and reduce hospital readmissions.

Medication Reconciliation Steps:

1. Collect Information: Obtain the best possible medication history, including pre-admission medications.
2. Compare Lists: Compare the pre-admission medication list with medications prescribed during the ICU stay and those planned for discharge.
3. Resolve Discrepancies: Identify and resolve any discrepancies (omissions, duplications, dose changes, new medications) in real-time, involving pharmacy and the medical team.
4. Communicate: Clearly communicate the final, reconciled medication list to the patient, caregivers, and outpatient providers.

Patient/Caregiver Education:

• Clearly explain the indication, dose, frequency, route, and common potential adverse drug events (ADEs) for each medication.
• Provide written information and a clear medication schedule.
• Educate on “red flag” symptoms warranting urgent medical attention (e.g., weight gain ≥ 2 kg in a week or 1kg overnight, worsening dyspnea, persistent dizziness, chest pain).
• Utilize the “teach-back” method to confirm understanding of key information.

Outpatient Follow-Up:

• Schedule a follow-up appointment with a cardiology or heart failure clinic, ideally within 7 days of discharge.
• Ensure clear communication of the hospital course, medication changes, and pending tests to the outpatient team.
• Leverage telemedicine for remote monitoring and early intervention if available and appropriate.

Address Social Determinants of Health:

• Assess for barriers to medication adherence, such as cost, access to pharmacy, transportation, and health literacy.
• Engage case management or social work services to help address identified socioeconomic challenges.

VI. Recognition & Initial Management of Mechanical Complications

Summary: Prompt recognition of acute mechanical complications of myocardial infarction (e.g., ventricular septal defect, papillary muscle rupture, free-wall rupture) is critical, as these are surgical emergencies requiring immediate stabilization and intervention.

Clinical Clues for Mechanical Complications:

• Sudden, profound hypotension or cardiogenic shock, often refractory to initial measures.
• Development of a new, harsh systolic murmur (e.g., pansystolic murmur in VSD or acute MR).
• Flash pulmonary edema.
• Signs of cardiac tamponade (if free-wall rupture with contained hematoma): pulsus paradoxus, jugular venous distension, muffled heart sounds.
• Equalization of diastolic pressures on invasive hemodynamic monitoring.

Immediate Stabilization Measures:

• Administer oxygen; intubate and mechanically ventilate if respiratory failure or severe distress.
• Provide hemodynamic support with inotropes (e.g., dobutamine) and vasopressors (e.g., norepinephrine) to maintain end-organ perfusion. Use judiciously to avoid worsening shunts or regurgitation.
• Careful volume resuscitation; avoid fluid overload, especially in acute mitral regurgitation or VSD.

Diagnostic Imaging:

• Urgent Echocardiogram (Transthoracic or Transesophageal): This is the primary diagnostic tool to visualize the defect (VSD, papillary muscle rupture leading to acute MR, free wall rupture), assess its hemodynamic consequences, and guide management.
• CT Angiography: May be considered if echocardiography is inconclusive or to assess for other complications.

Mechanical Circulatory Support (MCS) Escalation:

• Intra-Aortic Balloon Pump (IABP): Can provide afterload reduction and improve coronary perfusion, beneficial in acute MR or VSD.
• Percutaneous Ventricular Assist Devices (e.g., Impella, TandemHeart): May be used for more robust left ventricular unloading and systemic perfusion support.
• Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO): Indicated in cases of refractory cardiogenic shock or cardiac arrest, providing full cardiopulmonary support.

Surgical Coordination:

• Activate the cardiothoracic surgery team emergently upon suspicion or confirmation of a mechanical complication.
• The goal is to bridge the patient with MCS and medical therapy to definitive surgical repair as quickly as possible.