›IV infusion 10-20 mcg/min initial
›Titrate by 10-20 mcg/min every 5 minutes
›Maximum 400 mcg/min
›Less potent arterial vasodilator than nitroprusside
›Predominantly venodilator at lower doses
›Tachyphylaxis within 24 hours
›Dobutamine
›Cardiogenic shock with reduced forward output
›Combined with afterload reduction for hemodynamic optimization
›Dosing
›Initial 2-5 mcg/kg/min IV infusion
›Titrate by 2 mcg/kg/min every 10-15 minutes
›Maximum 20 mcg/kg/min
›Target MAP >= 65 mmHg with improved urine output
›Monitoring
›Tachycardia and arrhythmia risk
›Wean as hemodynamics permit and definitive treatment instituted
›Milrinone
›Alternative inotrope with vasodilatory properties
›Loading dose 50 mcg/kg IV over 10 minutes
›Maintenance 0.375-0.75 mcg/kg/min
›Reduce dose in renal impairment
›Advantage in beta-blocker-treated patients
›Mechanism bypasses beta receptor
›Furosemide IV
›Pulmonary congestion management
›Initial 0.5-1 mg/kg IV bolus (typically 40-80 mg IV)
›If chronic diuretic use, give 1-1.5 times oral dose IV
›Target urine output 0.5-1 ml/kg/hr
›High-dose or continuous infusion if bolus insufficient
›Infusion 5-40 mg/hr
›Electrolyte replacement essential
›Medications to avoid
›Pure vasoconstrictors (phenylephrine, norepinephrine as sole agent)
›Increase LV afterload and worsen regurgitant fraction
›Use only when vasodilatory shock coexists and MAP < 50 mmHg
›Beta-blockers in acute decompensated state
›Reduce compensatory tachycardia and may worsen cardiac output
›Not indicated in acute phase
Mechanical circulatory support
›Intra-aortic balloon pump
›Bridge to surgery in hemodynamically unstable patients
›Reduces LV afterload in diastole
›Increases diastolic coronary perfusion
›Contraindicated in moderate-severe aortic regurgitation
›Timing
›Insert before transfer if patient deteriorating
›Class IIa recommendation in cardiogenic shock from mechanical MI complications
›Impella ventricular assist device
›Refractory cardiogenic shock
›Impella CP (3.5 L/min) or Impella 5.0 (5 L/min) based on severity
›Unloads LV and increases forward cardiac output
›Contraindications
›Severe aortic stenosis or regurgitation
›LV thrombus
›Mechanical aortic valve
Endocarditis-specific treatment
›Empiric antibiotic therapy
›IVDU-associated or community-acquired
›Vancomycin IV 25-30 mg/kg loading dose
›Target AUC 400-600 mg-h/L or trough 15-20 mcg/ml
›Plus gentamicin 1 mg/kg IV every 8 hours if synergy indicated
›Prosthetic valve endocarditis
›Vancomycin plus gentamicin plus rifampin 300 mg PO/IV every 8 hours
›Duration minimum 6 weeks for prosthetic valve
›Tailor to culture results when available
›Penicillin G or ampicillin for susceptible streptococcal species
›Anti-staphylococcal penicillin (oxacillin) for MSSA if not MRSA