This patient should be started on dobutamine for probable cardiogenic shock. Cardiogenic shock is present when there is systemic hypotension and evidence for end-organ hypoperfusion, primarily due to inadequate cardiac output. Cardiogenic shock usually requires treatment with intravenous vasoactive medications and, in severe cases, device-based hemodynamic support. Manifestations of end-organ hypoperfusion may include acute kidney failure, elevated serum aminotransferase levels or hyperbilirubinemia, cool extremities, and decreased mental status. In this patient, initiating inotropic therapy is reasonable. Both dobutamine and milrinone are used to increase cardiac output; however, in the setting of kidney dysfunction, dobutamine would be the appropriate choice because milrinone is metabolized by the kidneys. Also, milrinone is a vasodilator, which could exacerbate his hypotension.
Mechanical therapy for cardiogenic shock should be considered in patients with end-organ dysfunction that does not rapidly show signs of improvement (within the first 12-24 hours) with intravenous vasoactive medications and correction of volume overload. Options for mechanical therapy include placement of an intra-aortic balloon pump and percutaneous or surgically implanted ventricular assist devices (VADs). An intra-aortic balloon pump is timed to inflate during diastole, augmenting coronary and systemic perfusion, and deflate during systole, reducing left ventricular afterload. It is premature to consider mechanical therapy for this patient.
Right heart catheterization can be helpful to guide therapy if volume status or cardiac output is uncertain. However, it has not been shown to improve outcomes in patients hospitalized with heart failure. This patient has clinical evidence of volume overload, including jugular venous distention, pulmonary crackles, edema to the mid thighs, pulmonary edema on chest radiography, and an S3. Additionally, he has evidence of low cardiac output (narrow pulse pressure, hypotension, acute kidney injury, mottled and cool extremities). Placement of a right heart catheter is not necessary prior to initiating inotropic therapy.