CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/hypotension-shockIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • MonitorFalse hypotension first: an open Y valve, air in the line, a loose connection, damping, contrast in a small catheter 1.
  • MonitorTrue hypotension: low pressure on a clean waveform, with a fast or slow rate.
  • PatientCold, clammy, confused or short of breath; low urine output 2.
  • LabLactate rising; SCAI shock stages A at risk, B beginning, C classic, D deteriorating, E extremis 2.
  • EchoVentricular function, a mechanical complication, an effusion, valve regurgitation 1.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Confirm it is real: check the transducer, the connections and the Y valve, and get a cuff pressure 1.
  2. Call for help and say the pressure out loud with the rhythm.
  3. Treat the obvious cause at once: deflate the balloon, pull back an Amplatz pushing the aortic cusp, stop the nitroglycerin 1.
  4. Sort the cause: bleeding (hypovolemia), pump (ischemia, valve, tamponade, rhythm) or vasodilation (vagal, anaphylaxis, drugs); right heart catheterization if unclear 1.
  5. Fluids for hypovolemia and vagal reactions; vasopressors when the mean pressure stays under 60 mmHg 3.
  6. Cardiogenic shock: revascularize the culprit; norepinephrine first; add an inotrope for low output 31.
  7. Mechanical support when shock persists: IABP, Impella or venoarterial ECMO by the hemodynamic profile 45.
  8. In STEMI shock a microaxial flow pump lowered death at 180 days in DanGer Shock 6.
  9. Arrest: CPR, and venoarterial ECMO if circulation does not return 1.

Equipment

From the complications cart. Linked items open in the equipment directory.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

  • Norepinephrine0.1 to 0.5 mcg/kg/min IV; the preferred vasopressor in cardiogenic shock 3.
  • Vasopressin0.03 units/min IV, titrated by 0.005 units/min every 10 to 15 minutes to 0.1 units/min 3.
  • Phenylephrine50 to 100 mcg IV bolus, then 0.5 to 1.4 mcg/kg/min; the choice in obstructive hypertrophic cardiomyopathy 3.
  • Epinephrine2 to 10 mcg/min IV in cardiogenic shock 3.
  • DobutamineInotrope for low output.Weight based dose in the Cath Med App
  • Atropine0.5 mg IV, repeat to 3 mg, for a vagal reaction 3.

Who to call

The escalation ladder, first call first.

  1. Shock team: early: interventional cardiology, heart failure, cardiac surgery and critical care 2.
  2. Anesthesia: airway and sedation.
  3. Perfusion: for ECMO.
  4. Cardiac surgery: for a mechanical complication or tamponade from rupture 1.

The bailout step by step

Placing an Impella CP in the lab 5

  1. Femoral access under ultrasound; 5 or 6 Fr sheath and femoral angiography to size the artery 5.
  2. Preclose with two suture devices at 10 and 2 o'clock 5.
  3. Stiff wire; dilate with 8, 10 and 12 Fr dilators; insert the 14 Fr sheath 5.
  4. Femoral angiography through the sheath to confirm leg perfusion 5.
  5. Heparin; cross the aortic valve with a pigtail and exchange for the pump wire.
  6. Advance the pump across the valve; confirm position by fluoroscopy and the console waveform; start support.
  7. Contraindications: mechanical aortic valve, left ventricular thrombus, severe aortic regurgitation, atrial or ventricular septal defect 5.

Prevent

  • Plan support for high risk PCI with abnormal hemodynamics 5.
  • Adequate hydration and sedation; watch nitroglycerin and verapamil doses 1.
  • Avoid prolonged balloon occlusion of large territories 1.

After care and documentation

  • Lactate, urine output and hemodynamics on a schedule; reassess the shock stage 2.
  • Limb checks for large bore devices.
  • Document the stage, the drugs, the device and the times.

Practice

Emergency simulator cases in the Cath Trainer app. The link opens Cases; type the case number in the search box.

  • EMG-0022: Anterior STEMI with a low pressure
  • EMG-0023: Hypotension in an inferior STEMI with clear lungs
  • EMG-0101: Cold, confused and breathless with an anterior STEMI
  • EMG-0038: Yawning, nausea and a soft pressure before the puncture

References

  1. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 28, Other complications: hypotension, radiation skin injury, contrast induced acute kidney injury.
  2. Naidu SS, Baran DA, Jentzer JC, et al. SCAI SHOCK stage classification expert consensus update: a review and incorporation of validation studies. J Am Coll Cardiol 2022;79:933-946.
  3. Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.
  4. Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care. J Am Coll Cardiol 2015;65:e7-e26.
  5. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 14, Hemodynamic support.
  6. Moller JE, Engstrom T, Jensen LO, et al. Microaxial flow pump or standard care in infarct-related cardiogenic shock. N Engl J Med 2024;390:1382-1393.
  7. CathLabHub Cath Trainer app, emergency simulator: case library (cathlabhub.com/app, Cases).

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/hypotension-shock. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.