Vasopressors And Inotropes


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Vasopressors And Inotropes

  1. 1. Vasopressors and Inotropes Critical Care Lecture Series
  2. 2. Objectives <ul><ul><li>What are the different classes of shock and give examples of each. </li></ul></ul><ul><ul><li>Discuss how to investigate and the management principles behind each of the causes of shock. </li></ul></ul><ul><ul><li>What are the different crystalloids and colloids available for resuscitation? </li></ul></ul><ul><ul><li>Have knowledge of the mechanism of action of commonly used vasopressors and inotropes, including dopamine, dobutamine, milnerone, levophed, phenylephrine, epinephrine, vasopressin </li></ul></ul><ul><ul><li>Discuss adverse events associated with the above agents. </li></ul></ul>
  3. 3. Is My Patient in Shock? <ul><li>Definition of shock </li></ul><ul><ul><li>Inadequate end organ perfusion leading to inadequate oxygen delivery </li></ul></ul><ul><li>N.B. a patient in shock does not have to be hypotensive </li></ul>
  4. 5. Treatment of Shock <ul><li>Basic Resuscitation: ABCDE’s </li></ul><ul><li>A: Airway establishment </li></ul><ul><li>B: Breathing: control WOB </li></ul><ul><li>C(a): Circulation Optimization </li></ul><ul><li>C(b): Control O2 consumption </li></ul><ul><li>D: Delivery of O2 adequately </li></ul><ul><li>E Extraction of O2 </li></ul>
  5. 6. Fluid resuscitation <ul><li>Very important…. </li></ul><ul><li>Therapy with least detrimental effects </li></ul><ul><li>Fluid therapy may be beneficial in any type of shock </li></ul><ul><ul><li>Even cardiogenic shock/pulmonary edema </li></ul></ul>
  6. 7. Fluid Resusitation <ul><li>Must “test the patient” </li></ul><ul><ul><li>Give volume and look for response/improvement </li></ul></ul><ul><ul><li>Always start with NS of RL </li></ul></ul><ul><ul><li>? Need blood </li></ul></ul><ul><li>Must always look for the effect of treatment </li></ul><ul><ul><li>Re-evaluate patient after fluid </li></ul></ul><ul><ul><li>If no improvement, and no adverse effects, repeat </li></ul></ul><ul><ul><li>If adverse effect, needs inotropes/vasopressor if still in shock </li></ul></ul><ul><li>Too much: pulmonary edema (O 2 sats) </li></ul>
  7. 8. A: Airway establishment <ul><li>Indications for intubation: </li></ul><ul><li>1. Failure of oxygenation or ventilation </li></ul><ul><li>2. Failure to protect airway </li></ul><ul><li>3. Condition present or procedure needed that will require intubation </li></ul><ul><li>“ shock” is an indication for intubation </li></ul><ul><li>Hypotension common after intubation </li></ul>
  8. 9. B: Breathing: control WOB <ul><li>Respiratory muscles are significant consumers of oxygen </li></ul><ul><li>Control will allow better O2 delivery to other tissues </li></ul><ul><li>Sedation after intubation </li></ul>
  9. 10. C(a): Circulation Optimization <ul><li>Most causes of shock require some volume re-expansion – even cardiogenic shock </li></ul><ul><li>- Starling curve </li></ul><ul><li>Crystalloid as good as colloid </li></ul><ul><li>Vasopressors ineffective if hypovolemic </li></ul><ul><ul><li>“double edged sword” </li></ul></ul>
  10. 11. C(b): Control O2 consumption <ul><li>Reduce hyper-adrenergic state </li></ul><ul><li>Analgesia/sedation/muscle relaxation </li></ul><ul><li>temperature </li></ul>
  11. 12. D: Delivery of O2 adequately <ul><li>Follow sats (keep > 92%) </li></ul><ul><li>? Transfusion (Hbg >80-100) </li></ul><ul><li>Lactate </li></ul><ul><li>SmvO2 </li></ul>
  12. 13. E: Extraction of O2 <ul><li>O2 must get from lungs to Hbg to tissues </li></ul><ul><li>O2 extraction important in some types of shock </li></ul><ul><ul><li>Cyanide, MetHbg, SEPSIS </li></ul></ul>
  13. 14. ABCDE’s: Summary <ul><li>A: Airway establishment : 02,biPap, ETT </li></ul><ul><li>B: Breathing : control WOB: Sedation, analgesia </li></ul><ul><li>C(a): Circulation Optimization : fluids, inotropes, pressors </li></ul><ul><li>C(b): Control O2 consumption : sedation, temp control, seizure control </li></ul><ul><li>D: Delivery of O2 adequately : Hbg, fluid, pressor, inotropes </li></ul><ul><li>E: Extraction of O2 : R/O cyanide, metHbg, sepsis </li></ul>
  14. 15. Vasopressors <ul><li>Many different pressors/inotropes </li></ul><ul><li>Need to understand how they work to use effectively </li></ul><ul><li>If choose wrong one, or use inappropriately, can harm the patient </li></ul><ul><ul><li>Adrenergic precipitation of arrhythmias </li></ul></ul><ul><ul><li>Drive the heart too fast resulting in decreased filling time and decreased stroke volume </li></ul></ul><ul><ul><li>Vasoconstriction of splachnic circulation and coronary arteries </li></ul></ul><ul><ul><li>Inotropes may make certain patients hypotensive </li></ul></ul>
  15. 16. Vasopressors <ul><li>β 1 agonist/stimulation: chronitropic, inotropic </li></ul><ul><li>β 2 agonist/stimulation: vasodilation, bronchodilation </li></ul><ul><li>α : vasoconstriction </li></ul><ul><li>D: increases renal blood flow </li></ul>
  16. 17. Vasopressors and inotropes: the chart (everything you need to know) Blood pressure Cardiac Output Low Normal Low Normal Need BP Need BP and CO Need nothing Need CO
  17. 18. Dopamine <ul><li>Dopaminergic, Beta, Alpha: ranges ? </li></ul><ul><li>Dopa: 1-5 ug/kg/min </li></ul><ul><ul><li>? Renal flow </li></ul></ul><ul><li>Beta: 5-10 ug/kg/min </li></ul><ul><ul><li>Inoptropy/chronotropy </li></ul></ul><ul><li>Alpha: >10 ug/kg/min </li></ul><ul><ul><li>Vasoconstriction </li></ul></ul><ul><li>Major use: increasing HR, ? bp </li></ul>
  18. 19. Dobutamine <ul><li>Beta (little alpha) </li></ul><ul><li>Inotropic/chronotropic </li></ul><ul><li>2-20 ug/kg/min </li></ul><ul><li>Major use: Systolic dysfunction </li></ul><ul><li>Caveat: can/will decrease MAP </li></ul>
  19. 20. Milrinone <ul><li>Used as an inotrope </li></ul><ul><li>Mechanism of Action </li></ul><ul><ul><li>Phosphodiesterase inhibitor </li></ul></ul><ul><ul><li>decrease the rate of cyclic AMP degradation </li></ul></ul><ul><ul><li>increase in cyclic AMP concentration leads to enhanced calcium influx into the cell, a rise in cell calcium concentration, and increased contractility </li></ul></ul><ul><li>Side Effects </li></ul><ul><ul><li>can also cause vasodilatation but tends to have less chronotropy than dobutamine </li></ul></ul><ul><li>Onset of action </li></ul><ul><ul><li>5-15 minutes </li></ul></ul><ul><li>Duration </li></ul><ul><ul><li>Half life of approximately 2 hours (so its gonna last a while </li></ul></ul><ul><li>Dose </li></ul><ul><ul><li>Loading dose: 50 mcg/kg administered over 10 minutes followed by 0.375 mcg/kg/minute </li></ul></ul>
  20. 21. Phenylepherine <ul><li>Pure alpha agonist </li></ul><ul><li>Vasoconstrictor with no effect on inotropy/chronotropy </li></ul><ul><li>0.2-3.0 ug/kg/min </li></ul><ul><li>Major use: non-cardiogenic hypotension </li></ul>
  21. 22. Norepinepherine <ul><li>Alpha and Beta </li></ul><ul><li>0.02-3.0 ug/kg/min </li></ul><ul><li>Major Use: when you need A&B </li></ul><ul><ul><li>? Drug of choice for septic shock </li></ul></ul>
  22. 23. Epinepherine <ul><li>Alpha and Beta </li></ul><ul><li>0.01 – 1.0 ug/kg/min </li></ul><ul><li>Major Use: when you need A&B </li></ul><ul><ul><li>resuscitation </li></ul></ul>
  23. 24. Vasopressors and inotropes Blood pressure Cardiac Output Low Normal Low Normal Phenylepherine Levophed (dopamine) Dopamine Levophed Epinepherine Or Dobutamine/phenyl nothing Dobutamine Milrinone
  24. 26. Overview of the Management of Shock
  25. 27. Case Study <ul><li>65 yo male presents to ED </li></ul><ul><li>Complaining of cough and feeling very unwell </li></ul><ul><li>HR 120, BP 100/60, RR 30, temp 39 </li></ul><ul><li>Is this patient in shock? </li></ul><ul><li>What investigations </li></ul><ul><li>What treatment would you start? </li></ul>
  26. 28. <ul><li>The patient’s BP drops to 90/50, what would you do now? </li></ul><ul><li>Would you start pressors? Which one? </li></ul>Case Study
  27. 29. Case Study <ul><li>The patient is on 0.8ug/kg/min of levophed through a femoral line. Why might the patient not be responding to the vasopressors? What measurement would be helpful in improving this man’s MAP? </li></ul>
  28. 30. Case Study <ul><li>The patient has been resuscitated, now has a BP of 110/90. HR 65. His JVP is 12. His lactate continues to rise however. He is also anuric. Is this patient in shock? What is your management now? </li></ul>
  29. 31. Summary <ul><li>Shock can be the consequence of decreased SVR, decreased CO or both. </li></ul><ul><li>Management of shock should be tailored to the physiologic state of the patient of the patient. </li></ul><ul><li>Drugs are available to augment SVR, HR, afterload and contractility. </li></ul><ul><li>Remember to optimize preload and consider the oxygen carrying capacity of the blood. </li></ul>