2025 PACUPrep BCCCP Preparatory Course Cardiogenic Shock Cardiogenic Shock: Monitoring, Complication Prevention, and Transition to Chronic Heart Failure Therapy
De-escalation of Intensive Therapies and Safe Transition to Chronic HF Management

De-escalation of Intensive Therapies and Safe Transition to Chronic HF Management

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Learning Objective

Develop a plan to facilitate patient recovery, mitigate long‐term complications, and ensure a safe transition of care.

1. Weaning Protocol for Intensive Therapies

Stepwise tapering of vasoactive agents, inotropes, and ventilator support as hemodynamics and perfusion improve reduces arrhythmia risk and myocardial stress.

A. Vasoactive Agents

  • Norepinephrine: Taper by 0.05–0.1 mcg/kg/min every 30–60 min; target MAP ≥ 65 mmHg, clear lactate, urine output > 0.5 mL/kg/h.
  • Vasopressin: Discontinue when NE ≤ 0.05 mcg/kg/min; taper slowly to avoid rebound hypotension.
  • Phenylephrine: Reserve for pure vasoplegia or tachyarrhythmias; reduce by 10–20 mcg/min decrements.
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  • Use the lowest effective dose and shortest duration of vasoactives.
  • Avoid abrupt withdrawal to prevent circulatory collapse.

B. Inotropes

  • Dobutamine: Decrease by 2.5 mcg/kg/min steps, guided by cardiac index and BP.
  • Milrinone: Reduce by 0.125–0.25 mcg/kg/min; adjust for renal function; monitor for hypotension.
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Switch to dobutamine if milrinone‐induced hypotension limits use.

C. Ventilatory Support

Daily spontaneous breathing trials (SBTs) and sedation minimization facilitate extubation and reduce ICU‐acquired weakness.

  • Perform SBTs once PaO₂/FiO₂ > 150–200 and vasopressor support is minimal.
  • Sedation: choose non‐benzodiazepines; conduct daily awakening trials.
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  • Assess cough strength, mental status, and oxygenation before extubation.
  • Tailor PEEP to balance oxygenation with preload and afterload effects.
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A detailed protocol for weaning temporary mechanical circulatory support (tMCS) is beyond this lesson scope; see primary guidelines for device flow reduction algorithms.

2. Conversion from IV to Enteral Medications

Transitioning to enteral therapy supports recovery and discharge planning—consider tube type, drug absorption, and feed interactions.

A. Enteral Access and Bioavailability Considerations

  • Access types: NG, PEG, J‐tube—verify placement radiographically; monitor residuals.
  • Drug factors: pH stability, site of absorption, interactions with enteral feeds; hold feeds 30–60 min around administration when needed.

B. Common IV→Enteral Conversions

Common Intravenous to Enteral Medication Conversions
Class IV Agent Enteral Alternative Approx. Bioavailability Dosing Notes
Proton pump inhibitor Pantoprazole IV Pantoprazole PO suspension/tablets ~80% No adjustment; ensure suspension suitable for tube
Beta‐blocker Esmolol IV Metoprolol succinate, Carvedilol 50–75% Start at low HF doses; up-titrate gradually
ACEi/ARB Enalaprilat IV Enalapril, Lisinopril ~60% mg-for-mg conversion; monitor renal function
Anticoagulant UFH IV LMWH/Warfarin/DOACs Varies Bridge warfarin until INR ≥2; adjust DOAC by eGFR
Diuretic Furosemide IV Furosemide PO ~50% Oral dose ~2× IV dose; monitor response
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Always confirm tube compatibility and consider pausing feeds to optimize drug absorption.

3. Post‐ICU Syndrome (PICS) Prevention

Early identification and mitigation of PICS through the ABCDEF bundle and mobility programs improve long‐term function.

A. Risk Stratification

  • High risk: mechanical ventilation > 48 h, high cumulative sedation, documented delirium.

B. ABCDEF Bundle Implementation

  • A: Awakening trials—daily sedation interruption
  • B: Breathing trials—daily SBTs
  • C: Choice of sedation—prefer non‐benzodiazepines
  • D: Delirium monitoring—use validated tools (e.g., CAM‐ICU)
  • E: Early mobilization—bed mobility → sitting → ambulation
  • F: Family engagement—involve caregivers in rounds and planning

C. Early Mobility and Rehabilitation

  • Initiate passive range‐of‐motion on day 1; advance as tolerated.
  • Pharmacy role: adjust analgesia/sedation to enable participation.
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  • Bundle adherence reduces ICU‐acquired weakness and delirium.
  • Coordinate sedation holds with physical therapy sessions.

4. Medication Reconciliation and Discharge Counseling

A structured reconciliation and education process minimizes errors and supports guideline‐directed medical therapy (GDMT) adherence.

A. Reconciliation Process

  • Compare pre‐admission, ICU, and discharge lists to identify omissions/duplications.
  • Adjust for changes in renal/hepatic function and hemodynamic stability.

B. Patient and Caregiver Education

  • Explain each drug’s indication, schedule, and side effects; use teach‐back.
  • Provide written action plans, symptom logs, and contact information.

C. Handoff and Follow‐Up Coordination

  • Pre‐schedule outpatient cardiology, pharmacy, and rehab appointments.
  • Arrange home health services; ensure primary care receives a complete summary.
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Use a discharge checklist to prevent overlooked medications.

5. Monitoring and Prevention of Complications During Transition

Vigilant tracking of perfusion, organ function, and device sites prevents adverse events as therapies are de‐escalated.

A. Hemodynamic and Perfusion Markers

  • Serial lactate (goal: clearance within 6–8 h)
  • MAP 65–70 mmHg, urine output > 0.5 mL/kg/h
  • Mentation: routine mental status checks or CAM‐ICU

B. Organ Function Surveillance

  • Daily labs: serum creatinine, BUN, liver enzymes, electrolytes
  • Mixed venous O₂ saturation if pulmonary artery catheter in place

C. Complication Watch

  • Telemetry: continuous arrhythmia surveillance
  • Vascular checks: pulses and Doppler for limb ischemia
  • Bleeding: inspect insertion sites, monitor hemoglobin/hematocrit
  • Infection: central‐line bundle compliance, temperature/white cell counts
Key Point Icon A checkmark, indicating an important point. Key Points

Early detection of limb ischemia or bleeding allows prompt intervention.

6. Transition to Chronic Heart Failure Therapy (Pharmacotherapy)

Initiate and up-titrate GDMT—beta‐blockers, ACEi/ARNI, MRAs, SGLT2i—once hemodynamic stability is achieved to improve survival and reduce readmissions.

A. Beta‐Blockers

  • Mechanism: β1 blockade reduces heart rate and myocardial oxygen demand.
  • Agents/dosing: Metoprolol succinate 12.5–25 mg QD; Carvedilol 3.125 mg BID.
  • Titration: Double dose every 1–2 weeks to target.
  • Monitoring: HR > 50 bpm, SBP > 90 mmHg, absence of congestion.
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Ensure euvolemia before initiation; avoid in active decompensation.

B. ACEi/ARNI

  • Mechanism: RAAS inhibition ± neprilysin blockade.
  • Agents: Enalapril 2.5–5 mg BID; Sacubitril/valsartan 24/26 mg BID.
  • Titration: Double every 2–4 weeks.
  • Monitoring: Renal function, K⁺ < 5.0 mmol/L, BP.
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Optimal timing of ARNI post‐shock stabilization.

C. Mineralocorticoid Receptor Antagonists

  • Mechanism: Aldosterone blockade reduces remodeling and fibrosis.
  • Agents: Spironolactone 12.5–25 mg QD; Eplerenone 25 mg QD.
  • Monitoring: K⁺, eGFR > 30 mL/min/1.73 m².

D. SGLT2 Inhibitors

  • Mechanism: Glycosuria and natriuresis with cardioprotective effects.
  • Agents: Dapagliflozin 10 mg QD; Empagliflozin 10 mg QD.
  • Fixed dosing; monitor renal function (eGFR threshold).
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Genital infections, euglycemic ketoacidosis risk.

E. Clinical Decision Points

  • Sequence: Initiate ACEi/ARNI + beta‐blocker → add MRA → add SGLT2i.
  • Adjust based on BP, renal/hepatic function, and volume status.
  • Engage multidisciplinary team for follow‐up titration plan.
Key Point Icon A checkmark, indicating an important point. Key Points
  • Early GDMT initiation post‐stabilization reduces mortality and readmissions.
  • Multidisciplinary follow‐up ensures adherence and timely dose adjustments.

References

  1. Sinha SS, Morrow DA, Kapur NK, et al. Concise clinical guidance: ACC expert consensus on cardiogenic shock management. J Am Coll Cardiol. 2025;85(16):1618–1641.
  2. Mathew R, Di Santo P, Jung RG, et al. Milrinone vs dobutamine in cardiogenic shock. N Engl J Med. 2021;385(6):516–525.
  3. Marbach JA, Stone S, Schwartz B, et al. Lactate clearance and survival in cardiogenic shock: meta-analysis. J Card Fail. 2021;27(10):1082–1089.
  4. Goldfarb MJ, Bechtel C, Capers Qt, et al. Engaging families in cardiovascular care: AHA scientific statement. J Am Heart Assoc. 2022;11(19):e025859.
  5. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure. Circulation. 2022;145(18):e895–e1032.
  6. Tehrani BN, Truesdell AG, Sherwood MW, et al. Standardized team-based care for cardiogenic shock. J Am Coll Cardiol. 2019;73(13):1659–1669.
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