Vasopressors in the Emergency room by John Greenwood
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John Greenwood discusses the use of vasopressors in the emergency room. His talk focuses on three areas. First, he reviews vasopressors and categorises them based on resuscitation end points. Secondly, he addresses the concept of “pressor angst” and how it can significantly impact patient mortality. Finally, he will empower you to start vasopressors early in patients with distributive shock and sepsis. The tale of a 45-year-old lady with sepsis in the context of pneumonia is retold. John asks - what do you do? Initial fluid resuscitation has improved the vitals somewhat, but she is still hypotensive. Continue to give fluids? Sure – it seems to be what happens commonly. Starting vasopressors starts a cascade of events that will consume time and resources. It impacts flow, timing and ability to see other patients. Often, the clinician knows it the right thing to do but does not want to pull the trigger. This process of having two conflicting beliefs in your brain at the same time is cognitive dissonance. In the context of using vasopressors, John terms this “pressor angst”. The hesitation to use vasopressors even when perhaps you know it is the right thing to do. It is a complex confliction of behaviours, beliefs, goals, and practices. Regarding vasopressors specifically, the clinician will be considering the logistics, bed crunch and procedures amongst other things! Why does the time matter? As John explains with reference to the literature, the time to the decision to commence vasopressors is hugely important in influencing patient mortality. There is a clear mortality benefit to starting vasopressors early. Norepinephrine started early can aid in adjusting preload, cardiac output, and afterload parameters. John steps you through the effect of norepinephrine on all metrics that contribute to. The conclusion is that early norepinephrine administration improves both macro- and microcirculatory function in vasoplegic shock. John wants you to avoid pressor angst! Do not be afraid of vasopressors and pull the trigger early. Finally, consider norepinephrine early in sepsis.
Vasopressors in the Emergency room by John Greenwood
- Practical Approach to Vasoactives Avoiding the Cognitive Dissonance of Pressor Angst John C. Greenwood, MD Emergency Medicine Critical Care Medicine University of Pennsylvania Philadelphia, PA USA @JohnGreenwoodMD
- Goals 1. Review vasopressors & categorize them based on resus end-points. 2. Discuss the concept of “Pressor Angst” & how it could significantly impact patient mortality. 3. Empower you to start vasopressors EARLY in patients with distributive shock.
- 45 y/o female presenting with PNA. VS: 39.5 110 101/38 [59] 22 92% 5L NC LA: 6 4 mmol/dL, post-30 cc/kg IVF
- Cognitive Dissonance Attitudes Customs Goals Practices Beliefs Behaviors Thoughts Evidence
- Pressor Angst Procedures Bed Crunch Logistics Charge Nurse Disposition Fluids Necessary? End points
- Pressor Angst Varpula, 2005 Dunser, 2009 Bai, 2014Varpula, 2005 Dunser, 2009 Bai, 2014 For each hour delay in NE initiation (within the first six hours), the mortality rate increased by 5.3%.
- Peripheral Pressors are SAFE 18-20g AC line Loubani OM et al. J Crit Care 2015; 30 (3): 653.e9 – 653.e17. Ricard JD et al. Crit Care Med 2013; 41: 2108 – 15. Cardenas-garcia J, et al. J Hosp Med. 2015;10(9):581-5.
- Hypovolemic Cardiogenic Obstructive Trauma GIBc.diff Vomiting Post-op DI STEMI Arrhythmia Regurgitation Myocarditis Diastolic dysfunction PE Tamponade HOCM PTX PHTN Sepsis Anaphylaxis Pancreatitis Post-CPB Neuro DistributiveDistributive De backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362(9):779-89.
- Hypovolemic Cardiogenic Obstructive Distributive Patient
- Macro-/Microcirc Targets
- Tank Pump Pipes
- Preload CO Afterload
- Volume PressorInotrope Preload CO Afterload
- Norepinephrine ˈnȯr-ˌe-pə-ˈne-frən
- MAPPPVCVPGEDVISVI NE Hamzaoui O, 2010. Monnet X, 2010. Preload CO Afterload [α β1]
- NE Hamzaoui O, 2010. Monnet X, 2010. Preload CVP PPV SVI GEDVI CO MAP Afterload [α β1]
- Early NE administration improves both Macro- & Microcirculatory function in vasoplegic shock.
- Trigger for early NE: DAP < 40 mmHg Signal of significant vasoplegia venous maldistribution, & unstressed intravascular volume Monnet X, 2011.
- NE on NE off
- Final Points • Delays in vasoactive administration for septic shock associated with significant increase in mortality. • Consider NE early in sepsis. Improves preload, improves microcirculation, limits fluid administration.