Fluid Management in Cardiogenic Shock

This chapter discusses cardiogenic shock, a common condition encountered in the ICU. Cardiogenic shock results from decreased cardiac output and manifests as end-organ ischemia. The key diagnostic criteria for cardiogenic shock are identified, and the different clinical presentations of left and right heart failure are described. Fluid management in patients with an impaired cardiac function is complex, and clinicians traditionally titrate fluid therapy based on central venous pressure and clinical examination. However, there may be an overemphasis on fluid restriction in patients with heart failure, and physicians need to identify the subgroup of patients with cardiogenic shock who might actually benefit from fluid replacement. Fluid boluses need to be titrated to specific end points of end-organ perfusion guided by dynamic measures of fluid responsiveness and repeated echocardiographic assessments. While the pulmonary artery (PA) catheter continues to be the gold standard in assessing hemodynamics and fluid requirements in these patients, less invasive or noninvasive modes have shown potential in providing equivalent information without the risks associated with the PA catheter. Understanding the etiology and type of heart failure is crucial in providing additional information and the likelihood of a favorable response to fluid resuscitation. Take-home messages include the importance of identifying different subtypes of cardiogenic shock and etiology, the definitive role of ultrasound and other invasive or noninvasive hemodynamic monitors to guide fluid management, and the need for carefully titrated fluid boluses to specific end points in patients with impaired cardiac function.