Ionotropes and vasopressor use in the ED

100 %
0 %
Information about Ionotropes and vasopressor use in the ED

Published on February 20, 2014

Author: jameswheeler001



Ionotropes and vasopressor use in the ED

Inotropes and Vasopressors for the ED 20th February 2014

Overview ED scenarios Indication for inotropes Choice of agent

Case 1 57 year old lady Brought in by husband as she has abdominal pain and seems slightly confused Obs T39, P128, BP 75/40, RR22, sats 98% OA, BSL 4.8 ECG Sinus tachycardia

How would you manage this patient?

Shock Shock is the failure to adequately oxygenate tissues to meet metabolic demand, resulting in end organ failure. Adjustable factors affecting tissue oxygenation [Hb] PaO2 Cardiac output Systemic vascular resistance

Which drug for this patient?

Noradrenaline Receptors Noradrenalin α1 e (some β1 at low doses) Action Dose μg/kg/min Side effects Vasoconstric tion and increased SVR 0.03-0.2 Increased afterload causing reduced SV and increased myocardial oxygen demand

Dopamine Receptors Action Dose μg/kg/min Dopamine Vasodilation of capillary beds, reduced SVR 1-3 β1 Increased SV and 3-10 CO α1 Vasoconstriction, >10 increased MAP Side effects Tachyarrythmia

Dopamine versus noradrenaline for the treatment of septic shock Meta-analysis by De Backer et al 2012 6 randomised trials, 1,408 patients Primary end point – mortality at 28 days 732 received dopamine, 676 to noradrenaline Median exposure 2 days Conclusion: Dopamine associated with greater mortality than noradrenaline and a greater number of arrhythmic events. Increased risk of death RR=1.12 (CI 1.01-1.20)

Back to the patient.. Access is difficult –just one pink line USS guided access is also attempted

Peripheral use of inotropes EMCRIT 107 French RCT where ICU patients were randomised to peripheral (n=128) or central access (n=135) Most complication in the peripheral group was extravasation injury Most common in CVC group was infectious Is extravasation an acceptable risk?

Case 2 32 year old male, football injury, presents with right shoulder pain

Management Obs Afebrile, P 80, BP 130/80, RR 20, Sats 100% OA, BSL 5.0 100mcg of fentanyl with the ambulance Anaesthetic assessment, fasted, no regular medications, ECG sinus He is sedated and the shoulder is relocated.

Case 2 continued Shoulder relocated Obs P 60, BP 65/40, RR 20, Sats 100% OA, BSL 5.0

Receptors Action Dose Side effects Metaraminol Indirect Vasoconstric release of NA tion 0.5mg bolus Hypertension tachycardia Adrenaline Low dose β 1>β2 <0.02 HTN, tachyarrythmia, Hyperglycaemia, hypokalaemia High dose α1 Increased HR, SV and CO >0.02

Push dose pressors Indication is transient hypotension During sedation Post intubation Whilst waiting for inotropes to work or CVC lines to be sited Transfers

Case 3 84 year old lady PC: Dizzyness and palpitations HPC: Felt light headed on standing, developed palpitations and central burning chest pain associated with SOB and a feeling that she might collapse. Pain lasted 10 mins. Obs Afebrile, P40, BP 209/100, RR22, 96% OA, BSL 6.3


Meanwhile.. Called to see the patient who has had a short lived presyncopal episode Obs Afeb HR 20, BP 180/90, RR 20, 96%OA ECG


What is your management?

Complete heart block Reversible causes – ischaemia, drugs Discussed with Cardiology consultant: admit to CCU for telemetry and isoprenaline

Isoprenaline Receptors Isoprenaline Action Dose B1>B2 Positive Infusion 0.5inotrope and 5 mcg/min chronotrope, Side effects Increases myocardial oxygen demands

Summary What kind of drugs can we use? Iontropes Adrenaline Dobutamine Vasopressors Noradrenaline Metarminol Chronotropes Isoprenaline

Summary Actions of these drugs depend on the receptors they activate and the concentration of the drug Most commonly used for management of shock Determining the type of shock is important in choice of drug Range of application in the ED Bridging therapy to allow treatments for shock to take effect To counteract transient effects of other drugs

References De Backer et al. (2012) Dopamine versus norepinephrine in the treatment of septic shock: A meta-analysis. Crit Care Med. Vol 40. p 725 Senz A (2009) Review article: inotrope and vasopressor use the emergency department. Emerg Med Australas. 2009 Oct;21(5):342-51 Benham-Hermetz (2012) Cardiovascular failure, inotropes and vasopressors British Journal of Hospital Medicine May,Vol73,No5 EMCRIT Podcast 107 RAGE Podcast 1 Push dose pressors April 2013

Add a comment

Related presentations

Related pages

Use of Vasopressors and Ionotropes - Home Page ...

Use of Vasopressors and Ionotropes. ... Choice of Vasopressor use . ... A 21 year old female with no significant past medical history presents to the ED ...
Read more

Ionotropes and vasopressor use in the ED - Documents

05 Inotropic and Vasopressor Support Program Anestesiologi & Cawangan Kualiti Penjagaan kesihatan BPP, KKM ICU Management Protocol No. 5 INOTROPIC AND ...
Read more

Inotropes, vasopressors and other vasoactive agents ...

... Inotropes, vasopressors and other vasoactive agents. Inotropes, ... […] and vasopressor use in the ED from SCGH ED CME Here is Ros’ talk, ...
Read more

CME 20/02/14 - Ionotrope and vasopressor use in the ED ...

ionotrope and vasopressor use in the emergency department. ... Ionotropes and vasopressor use in the ED from SCGH ED CME. Here is Ros’ talk.
Read more

Vasopressors & Inotropes in the ED | Emergency Medicine ...

Vasopressors & Inotropes in the ED. ... You are aware that the surviving sepsis campaign advocates use of a vasopressor to maintain a MAP >65mmHg in septic ...
Read more

Vasopressor and Inotrope Use in Canadian Emergency ...

Vasopressor and Inotrope Use in Canadian Emergency Departments: Evidence Based Consensus ... with vasopressor or inotrope use in shock states in the ED.
Read more

Vasopressors and Inotropes in Shock -

Early vasopressor use within the first 24 hours in ... Vasopressors and Inotropes in Shock Author: 001908 Created Date: 5/12/2011 12:23:33 PM ...
Read more

North American Survey of Vasopressor and Inotrope Use in ...

A 1996 survey of vasopressor and inotrope use showed that 65% of 54 respondents indicated ... a unifi ed system for every patient, everywhere.
Read more