In cardiogenic shock with pulmonary congestion, when should diuretics be used?

• A. Before any inotrope
• B. Never
• C. Only after inotropes stabilize
• D. Before stabilization

Answer: (C)

The key idea is balancing preload relief with maintaining adequate forward flow. In cardiogenic shock, the priority is to restore perfusion; inotropes improve cardiac output and blood pressure, helping organs get blood. Diuretics pull fluid off the lungs by reducing preload, but lowering preload too soon can drop venous return and worsen hypotension and renal perfusion. So you want the heart to have some stabilization of contractility and perfusion with inotropes first, then use diuretics to unload the congested lungs once hemodynamics are more robust. Start diuresis cautiously after stabilization, monitoring urine output, blood pressure, and kidney function. In difficult cases, if perfusion remains poor, reassess and consider additional support.