What is the optimal acute management for a 63‑year‑old woman with known ischemic heart disease who presents with fever, acute respiratory failure requiring intubation, severe left‑ventricular systolic dysfunction (ejection fraction ≈30 %), acute kidney injury, markedly elevated pro‑calcitonin, and is already receiving inotropic support?

Acute Management of Cardiogenic Shock with Suspected Sepsis

This patient requires immediate aggressive treatment for cardiogenic shock with concurrent broad-spectrum antibiotics for presumed sepsis, given the markedly elevated procalcitonin (70 ng/mL) following recent fever, while continuing inotropic support and optimizing mechanical ventilation. 1, 2

Immediate Priorities in the ICU

Hemodynamic Support

• Continue inotropic support as the patient is already receiving inotropes for cardiogenic shock with severely reduced ejection fraction (30%) and evidence of end-organ hypoperfusion (elevated creatinine). 1
• If hypotension persists despite inotropes, add vasopressor support with norepinephrine as the first-line agent to maintain systemic perfusion and preserve end-organ function. 2
• Consider invasive hemodynamic monitoring (pulmonary artery catheter) given the complex picture of cardiogenic shock with acute kidney injury and unclear volume status—this is particularly useful when renal function is worsening despite therapy. 1

Infection Management

• Initiate broad-spectrum antibiotics immediately given the procalcitonin of 70 ng/mL following recent fever, which strongly suggests bacterial infection despite the caveat that procalcitonin can be elevated in acute kidney injury. 2, 3
• The extremely high procalcitonin level (70 ng/mL) in the context of recent fever makes infection highly likely, even though procalcitonin cannot reliably differentiate infected from non-infected patients when creatinine is ≥2 mg/dL. 3
• Obtain blood cultures, urine cultures, and consider respiratory cultures before antibiotic administration but do not delay antibiotics. 2

Respiratory Management

• Continue mechanical ventilation with lung-protective strategies, monitoring oxygenation and ventilation parameters closely. 1
• Monitor arterial blood gases to assess for hypoxemia, hypercapnia, and acidosis. 1
• The need for intubation in this setting is appropriate given respiratory failure with cardiogenic pulmonary edema. 1

Fluid and Diuretic Management

Volume Assessment

• Perform urgent echocardiography (if not already done) to assess cardiac filling pressures, valvular function, and exclude mechanical complications of ischemic heart disease. 1
• Given the elevated pro-BNP and low ejection fraction, this patient likely has significant volume overload contributing to respiratory failure. 1

Diuretic Strategy

• Administer intravenous loop diuretics (furosemide at a dose equal to or exceeding any chronic oral dose) to relieve pulmonary congestion, even in the setting of acute kidney injury. 1
• Monitor urine output hourly and titrate diuretic dose accordingly—if diuresis is inadequate, consider higher doses, continuous infusion, or addition of a thiazide diuretic. 1
• Daily monitoring of fluid balance, weight, electrolytes, and renal function is essential during aggressive diuresis. 1, 4

Acute Kidney Injury Management

Monitoring and Assessment

• Daily measurement of serum creatinine, urea, and electrolytes to track acute kidney injury progression. 1, 4
• The acute kidney injury in this setting is likely multifactorial: cardiogenic shock with hypoperfusion, venous congestion from heart failure, and possible sepsis-related acute tubular necrosis. 5
• Acute kidney injury in the setting of cardiogenic shock is associated with significantly higher mortality (50% vs 2.2% in one study) and is an independent predictor of in-hospital death. 5

Balancing Diuresis and Perfusion

• Do not withhold diuretics solely because of acute kidney injury—relieving congestion may actually improve renal perfusion by reducing venous congestion. 1
• If oliguria persists despite adequate filling pressures and inotropic support, consider whether renal replacement therapy may be needed. 5

Ischemic Heart Disease Considerations

Urgent Revascularization Assessment

• Consider urgent cardiac catheterization if there is evidence of acute myocardial ischemia or if the patient has not had recent coronary evaluation, as revascularization may be life-saving in cardiogenic shock. 1
• In patients with known ischemic heart disease presenting with acute heart failure and signs of inadequate systemic perfusion, urgent catheterization and revascularization is reasonable where it is likely to prolong meaningful survival. 1

Medical Management

• Continue aspirin and statin therapy unless contraindicated. 1
• Beta-blockers should NOT be initiated or up-titrated during the acute phase while the patient requires inotropic support—these should only be restarted at low doses after stabilization and discontinuation of inotropes. 1

Critical Monitoring Parameters

Daily Assessment Should Include:

• Hemodynamic parameters: blood pressure, heart rate, central venous pressure (if available), cardiac output/index (if invasive monitoring in place). 1, 4
• Perfusion markers: lactate levels, mental status, urine output, skin perfusion. 2, 4
• Respiratory status: oxygen requirements, ventilator settings, arterial blood gases. 1
• Renal function: creatinine, urea, urine output, electrolytes (particularly potassium and magnesium). 1, 4
• Infection markers: temperature, white blood cell count, repeat procalcitonin if needed to assess response to antibiotics. 2

Common Pitfalls to Avoid

Procalcitonin Interpretation

• Do not dismiss the possibility of infection despite acute kidney injury—while procalcitonin is less specific in renal dysfunction, a level of 70 ng/mL following fever strongly suggests bacterial infection. 3
• The study showing procalcitonin unreliability in acute kidney injury found that when creatinine ≥2 mg/dL, median procalcitonin levels were similar in infected and non-infected cardiac surgery patients, but extremely high values (>70) still warrant aggressive infection management. 3

Inotrope Management

• Avoid routine or prolonged inotrope use beyond what is necessary for cardiogenic shock, as continuous intravenous inotropic support outside of shock states is potentially harmful. 1
• Once hemodynamic stability is achieved, work toward weaning inotropes as soon as possible. 1

Volume Status Assessment

• Do not assume the patient is "dry" simply because of acute kidney injury—patients with heart failure and elevated pro-BNP typically have significant volume overload requiring aggressive diuresis. 1
• Invasive hemodynamic monitoring is particularly useful when fluid status is uncertain in the setting of worsening renal function. 1

Transition Planning

Once Stabilized:

• Transition from intravenous to oral diuretics with careful attention to dosing and monitoring of electrolytes and renal function. 1
• Initiate or optimize guideline-directed medical therapy for heart failure with reduced ejection fraction (ACE inhibitors/ARBs, beta-blockers, mineralocorticoid receptor antagonists) only after hemodynamic stability is achieved and inotropes are discontinued. 1
• Early cardiology follow-up within 7 days of discharge is crucial for high-risk patients to optimize heart failure management and reduce readmission risk. 6