A 26-year-old woman with no prior medical history presents t…
A 26-year-old woman with no prior medical history presents to the emergency department (ED) with progressively worsening dyspnea for 1 week. Her symptoms are preceded by 3 days of fever, rigors, and nasal congestion. She is afebrile with HR of 116 beats/min and BP of 92/70 mmHg. Physical examination reveals bilateral rales, elevated jugular venous pressure, 2/6 systolic murmur at the left lower sternal border, cool extremities, and 2+ bilateral lower extremity edema. Echocardiogram reveals LVEF of 20%, nondilated LV (LV end-diastolic diameter of 3.4 cm), global hypokinesis, mild mitral regurgitation, and a normal right ventricular function. Labs are significant for creatinine of 1.6 mg/dL, aspartate aminotransferase (AST) of 385 U/L, alanine aminotransferase (ALT) of 413 U/L, troponin I of 4.8 ng/mL, and serum lactic acid of 2.8 mmol/L. Intravenous diuretics and dobutamine are initiated. Within 24 hours of admission, the patient develops hypotension and worsening heart failure refractory to inotropes and vasopressors. Urine output is 125 cc in the last 6 hours. Which of the following is the best next step in her management to stabilize her?