Published on February 20, 2014
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 http://emcrit.org/podcasts/peripheralvasopressors-extravasation/ RAGE Podcast 1 http://ragepodcast.com/rage-session-one/ Push dose pressors April 2013 http://www.emrap.org/episode/2013
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