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Vasopressors in the Emergency room by John Greenwood

  1. 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
  2. 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.
  3. 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
  4. Cognitive Dissonance Attitudes Customs Goals Practices Beliefs Behaviors Thoughts Evidence
  5. Pressor Angst Procedures Bed Crunch Logistics Charge
 Nurse Disposition Fluids Necessary? End points
  6. 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%.
  7. 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.
  8. 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.
  9. Hypovolemic Cardiogenic Obstructive Distributive Patient
  10. Macro-/Microcirc Targets
  11. Tank Pump Pipes
  12. Preload CO Afterload
  13. Volume PressorInotrope Preload CO Afterload
  14. Norepinephrine ˈnȯr-ˌe-pə-ˈne-frən
  15. MAPPPVCVPGEDVISVI NE Hamzaoui O, 2010. Monnet X, 2010. Preload CO Afterload [α β1]
  16. NE Hamzaoui O, 2010. Monnet X, 2010. Preload CVP PPV SVI GEDVI CO MAP Afterload [α β1]
  17. Early NE administration improves both Macro- & Microcirculatory function in vasoplegic shock.
  18. Trigger for early NE: DAP < 40 mmHg Signal of significant vasoplegia venous maldistribution, & unstressed intravascular volume Monnet X, 2011.
  19. NE on NE off
  20. 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.