In a post‑percutaneous coronary intervention patient on norepinephrine and isoproterenol infusions, with blood pressure 107/69 mmHg, heart rate 95 bpm, respiratory rate 28/min, SpO₂ 95% on 2‑3 L/min nasal cannula, positive fluid balance, cough but no chest pain, how should we manage him—including vasopressor weaning, assessment of the cough, and optimization of guideline‑directed medical therapy?

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Last updated: February 24, 2026 • View editorial policy

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Manejo ng Post-PCI Patient na May Hemodynamic Instability

Immediate Assessment at Kahulugan ng Problema

Ang pasyente ay may hemodynamic instability na nangangailangan ng urgent intervention dahil sa kombinasyon ng tachypnea (RR 28), borderline hypotension (BP 107/69), at patuloy na pangangailangan ng vasopressor support. 1

Ang mga critical findings na dapat i-assess:

  • Tachypnea (RR 28/min) na may ubo – kailangan i-rule out pulmonary edema, pulmonary embolism, o pneumonia post-PCI 2
  • Borderline blood pressure (107/69 mmHg) – nasa threshold lang ng acceptable MAP (>65 mmHg) 2
  • Positive fluid balance – 613 mL intake vs 1200 mL output ay negative balance, pero may consumed na Norepi at Isoket drips 2
  • Walang chest pain – good sign na walang ongoing ischemia 2
  • Hindi nakatulog – possible sign ng discomfort o respiratory distress 2

Vasopressor Weaning Strategy

Dapat i-wean ang norepinephrine at isoproterenol (Isoket) nang gradual habang closely monitoring ang hemodynamics, targeting MAP ≥65 mmHg. 2

Algorithm para sa Vasopressor Weaning:

  1. I-assess muna kung stable ang patient – kung MAP consistently >70 mmHg for 30 minutes, pwede mag-start ng weaning 2

  2. I-wean ang isoproterenol (Isoket) FIRST dahil:

    • Mas mataas ang risk ng myocardial ischemia sa post-PCI patients 3, 4
    • May ultra-short half-life (2-5 minutes) kaya rapid ang effect ng dose reduction 5
    • Nag-i-increase ng myocardial oxygen demand habang nag-re-reduce ng coronary perfusion 3

  3. Reduce isoproterenol by 25-50% every 15-30 minutes habang nimo-monitor ang:

    • Heart rate (target 60-100 bpm) 1
    • Blood pressure (maintain MAP ≥65 mmHg) 2
    • Signs ng ischemia (chest pain, ECG changes) 2

  4. Pagkatapos ma-wean ang isoproterenol, i-wean ang norepinephrine:

    • Reduce by 0.05-0.1 mcg/kg/min every 15-30 minutes 6
    • Target MAP 65-75 mmHg 2
    • Monitor for hypotension 2

Assessment ng Ubo at Tachypnea

Ang ubo na may tachypnea post-PCI ay dapat i-evaluate aggressively para sa pulmonary edema, pulmonary embolism, o pneumonia. 2

Immediate Diagnostic Workup:

  • Chest X-ray STAT – check for pulmonary congestion, infiltrates, o pneumothorax 2
  • Arterial blood gas (ABG) from RIGHT RADIAL artery – assess oxygenation at ventilation status 2
  • 12-lead ECG – rule out ongoing ischemia o arrhythmias 2, 1
  • Cardiac enzymes (Troponin) – check for peri-procedural MI 2
  • BNP/NT-proBNP – assess for heart failure 2

Management Based on Findings:

Kung pulmonary edema:

  • Initiate diuretic therapy (furosemide 20-40 mg IV) 2
  • Elevate head of bed 30° 2
  • Consider non-invasive ventilation kung worsening respiratory distress 2

Kung suspetsa ng pulmonary embolism:

  • Urgent CT pulmonary angiography 2
  • Consider anticoagulation kung walang contraindication 2

Kung pneumonia:

  • Start empiric antibiotics (amoxicillin-clavulanic acid IV) 2
  • Blood cultures before antibiotics 2

Oxygen Support Optimization

Ang current oxygen support (nasal cannula 2-3 L/min achieving SpO₂ 95%) ay borderline; dapat i-titrate to maintain SpO₂ >92% habang avoiding hyperoxia. 2

  • Target SpO₂: 92-96% – avoid hyperoxia na pwedeng mag-cause ng oxygen toxicity 2
  • Kung RR >25 o SpO₂ <92% despite 4-6 L/min nasal cannula, consider:
    • High-flow nasal cannula 2
    • Non-invasive ventilation (BiPAP/CPAP) 2
    • Intubation kung may signs ng respiratory failure 2

Guideline-Directed Medical Therapy (GDMT) Post-PCI

Dapat i-ensure na naka-start na ang lahat ng evidence-based medications para sa post-PCI care. 2

Essential Medications:

  1. Dual Antiplatelet Therapy (DAPT):

    • Aspirin 75-100 mg daily indefinitely 2
    • P2Y12 inhibitor (clopidogrel 75 mg o ticagrelor 90 mg BID) for at least 12 months 2

  2. Statin Therapy:

    • High-intensity statin (atorvastatin 40-80 mg o rosuvastatin 20-40 mg) 2
    • Continue unchanged kung naka-start na 2

  3. ACE Inhibitor o ARB:

    • Start o continue kung may LV dysfunction, hypertension, o diabetes 2
    • Hold temporarily kung hypotensive (SBP <100 mmHg) 1

  4. Beta-blocker:

    • HOLD MUNA habang naka-vasopressor support dahil may bradycardia risk 1
    • Start once hemodynamically stable (off vasopressors, HR >60, SBP >100) 1

Fluid Management

Ang negative fluid balance (1200 mL output vs 613 mL intake) ay acceptable kung stable ang blood pressure, pero dapat i-monitor closely. 2

  • Maintain euvolemia – avoid fluid overload na pwedeng mag-worsen ng pulmonary edema 2
  • Kung may signs ng hypovolemia (low CVP, poor skin turgor, oliguria):
    • Give 250-500 mL normal saline bolus 2
    • Reassess after each bolus 2

Monitoring Parameters

Dapat i-monitor ang patient closely sa ICU o step-down unit habang naka-vasopressor support. 1

Vital Signs Monitoring:

  • Blood pressure every 15 minutes habang nag-we-wean ng vasopressors 6
  • Heart rate continuous monitoring – watch for bradycardia (<50) o tachycardia (>100) 1
  • Respiratory rate at SpO₂ continuous – target RR <20, SpO₂ >92% 2
  • Urine output hourly – target >0.5 mL/kg/hr 2

Laboratory Monitoring:

  • Hematocrit – check for bleeding (decrease >5-6% ay significant) 2
  • Renal function – monitor for contrast-induced nephropathy 2
  • Cardiac enzymes – peak at 12-24 hours post-PCI 2

Critical Pitfalls to Avoid

  • Huwag mag-delay ng transcutaneous pacing kung mag-develop ng symptomatic bradycardia habang nag-we-wean ng vasopressors 2, 1
  • Huwag mag-start ng beta-blocker habang naka-vasopressor support – may risk ng severe bradycardia 1
  • Huwag mag-ignore ng tachypnea – pwedeng sign ng pulmonary embolism o heart failure 2
  • Huwag mag-hyperventilate kung mag-intubate – target PETCO₂ 35-40 mmHg 2
  • Huwag mag-delay ng chest X-ray para sa assessment ng ubo 2

Disposition at Follow-up

Ang patient ay dapat manatili sa ICU o high-dependency unit hanggang:

  • Successfully weaned off vasopressors for at least 6-12 hours 1
  • Hemodynamically stable (MAP >65 mmHg, HR 60-100, RR <20) 2, 1
  • Respiratory symptoms resolved 2
  • No evidence ng ongoing ischemia o complications 2

References

1
Guideline

Management of Symptomatic Bradycardia

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Guideline

Mechanism and Clinical Implications of Isoproterenol

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

5
Guideline

Isoproterenol Pharmacokinetics and Clinical Use

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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