# Simulated case set: Advanced hemodynamic reasoning > **Educational work by a pre-medical student — not medical advice.** Not a clinical protocol, prescription, or patient handout, and not for patient care. See [DISCLAIMER](DISCLAIMER.md). Entirely synthetic independent premedical study material. Revised 27 October 2026. The author confirmed that scenarios are independent of real encounters/charts. This reconstruction preserves the earlier topic coverage while withdrawing unsupported medication doses, device adjustments and automatic escalation thresholds. Earlier versions remain in Git history. ## How to use these worked examples Read the paired patient examples and integrated clinical narratives linked under each scenario. The examples explain interpretation and conditional care decisions; no student answers or scoring are required. See the [procedure-organized CTICU casebook](CTICU_PROCEDURE_EXAMPLES.md) and [source guide](references/bibliography.md). ## Scenario 1: Shock immediately after CABG [Paired synthetic application examples](APPLIED_CASES.md#icu-02-01). [Integrated workup and test reasoning](ICU_CTICU_WORKUP_CASES.md#icu-02-01). **Synthetic vignette:** A fictional adult after coronary bypass has hypotension, low estimated output, hypothermia and ongoing drain output. **Worked example interpretation** Use surgical assessment and verified output measurements to distinguish blood loss from pump failure, while allowing coexistence. A vasopressor, inotrope or transfusion discussion addresses different mechanisms; none is selected solely by MAP. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment. **Interpretation boundary:** A single cardiac-index or drain-output cutoff is not a complete treatment rule. ## Scenario 2: VA-ECMO after myocardial infarction [Paired synthetic application examples](APPLIED_CASES.md#icu-02-02). [Integrated workup and test reasoning](ICU_CTICU_WORKUP_CASES.md#icu-02-02). **Synthetic vignette:** A fictional adult on VA-ECMO has improving lactate but oliguria and concern about limb perfusion. **Worked example interpretation** Falling lactate does not settle limb perfusion or kidney questions; evaluate each organ and circuit configuration. Anticoagulation, vasoactive and analgesic choices require bleeding/perfusion context and specialist oversight. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment. **Interpretation boundary:** Post-oxygenator oxygenation does not alone establish upper-body oxygenation. Flow changes, cannula procedures and renal-support prescriptions require an ECMO team. ## Scenario 3: Early LVAD and RV function [Paired synthetic application examples](APPLIED_CASES.md#icu-02-03). [Integrated workup and test reasoning](ICU_CTICU_WORKUP_CASES.md#icu-02-03). **Synthetic vignette:** A fictional adult after LVAD implantation has changing displayed flow and pulsatility with borderline RV function. **Worked example interpretation** Interpret loading, rhythm, ventricular interaction and device data together before assigning a device cause. Fluid and vasoactive changes are not substitutes for device assessment; no universal speed or dose follows from a display value. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment. **Interpretation boundary:** No universal pulsatility-index target, CVP range, speed change or anticoagulation sequence is established here. ## Scenario 4: Pneumonia-associated ARDS [Paired synthetic application examples](APPLIED_CASES.md#icu-02-04). [Integrated workup and test reasoning](ICU_CTICU_WORKUP_CASES.md#icu-02-04). **Synthetic vignette:** A fictional adult with ARDS has a reported P:F ratio near 87, increased driving pressure and vasopressor support. **Worked example interpretation** Check comparability and mechanics before grading severity; assess lung protection and hemodynamic tolerance before discussing conditional adjuncts. Corticosteroids or neuromuscular blockade are indication-dependent options in the cited guideline, not automatic responses to a ratio. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment. **Interpretation boundary:** A reported ratio is not a self-contained rescue protocol. Ventilator mode names do not guarantee lung protection. ## Scenario 5: Aortic repair, hypertension and AKI [Paired synthetic application examples](APPLIED_CASES.md#icu-02-05). [Integrated workup and test reasoning](ICU_CTICU_WORKUP_CASES.md#icu-02-05). **Synthetic vignette:** A fictional adult after type A dissection repair develops hypertension, oliguria and rising creatinine. **Worked example interpretation** Assess anatomy and organ perfusion as well as pressure; distinguish possible malperfusion from congestion or medication-related kidney changes. Rate/pressure-control discussion is specific to repair and perfusion; repeated fluid or antihypertensive changes are not an imaging substitute. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment. **Interpretation boundary:** No blood-pressure prescription or delay-to-imaging rule is supplied. ## Scenario 6: Lung transplantation and graft dysfunction [Paired synthetic application examples](APPLIED_CASES.md#icu-02-06). [Integrated workup and test reasoning](ICU_CTICU_WORKUP_CASES.md#icu-02-06). **Synthetic vignette:** A fictional lung-transplant recipient develops poor compliance, impaired gas exchange and fluid accumulation. **Worked example interpretation** Check transplant timing, imaging and competing causes before using PGD classification; donor/recipient size and mechanics need context. Diuresis, ventilator support and immune therapy answer different questions; none is established by poor compliance alone. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment. **Interpretation boundary:** Blanket PEEP reduction, fixed diuresis targets and an assumed immunosuppression regimen are withdrawn. Transplant-specific care is specialist work. ## Scenario 7: Sepsis and an open abdomen [Paired synthetic application examples](APPLIED_CASES.md#icu-02-07). [Integrated workup and test reasoning](ICU_CTICU_WORKUP_CASES.md#icu-02-07). **Synthetic vignette:** A fictional adult with abdominal sepsis has worsening shock, oliguria and positive fluid balance. **Worked example interpretation** Review source control and measured pressure with new organ dysfunction; isolated pressure is not the whole syndrome. Antimicrobial and hemodynamic treatment require reassessment; no dressing manipulation or fixed fluid-removal rate is implied. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment. **Interpretation boundary:** A pressure number alone does not diagnose abdominal compartment syndrome or authorize altering a surgical dressing. ## Scenario 8: SAH with stress cardiomyopathy [Paired synthetic application examples](APPLIED_CASES.md#icu-02-08). [Integrated workup and test reasoning](ICU_CTICU_WORKUP_CASES.md#icu-02-08). **Synthetic vignette:** A fictional adult after aneurysm treatment has cardiac dysfunction and concern about cerebral perfusion. **Worked example interpretation** Check cerebral perfusion measurements and whether symptomatic delayed ischemia is present before discussing competing circulatory goals. Nimodipine and hemodynamic augmentation have different indications; prophylactic hypertension or a fixed sodium regimen is not inferred. The linked paired example and integrated narrative explain the patient-specific context, investigation purposes and reassessment. **Interpretation boundary:** No prophylactic hypertension, hypervolemia or fixed hypernatremia regimen is supplied.