Published on December 11, 2013
Resuscitating the Hypotensive Patient Kane Guthrie FCENA
Hypotensive Resuscitation • Look at shock • Fluid resuscitation • Pharmacology of vasoactive medications • Current evidence • Case Studies
Shock Inadequate oxygen delivery to meet tissue demands
Shock is a time-dependant disorder!
Epidemiology of Shock
Diagnosing Shock 3 components • Systemic arterial hypotension • Clinical signs tissue hypoperfusion • Hyperlactatemia
Hypotension is Bad
Hypotension in ED • Independently predicts in-hospital mortality • Risk of death increases: • SBP <80mmHg • Sustained hypotension >60min
Hypotension Predicts Mortality • Pulmonary Embolism • Myocardial Infarction • Traumatic Brain Injury • Sepsis
Assessing the Shocked Patient • Physical exam can assess overall tissue perfusion: • Assess mental status • • Assess skin • • Are patients confused?, dizzy?, drowsy? Is the skin cool or mottled? Assess kidney perfusion • Is urine output less than 0.5 mL/kg/hour?
Laboratory Assessment • Laboratory testing can be used to assess perfusion: • Elevated serum creatinine • • Elevated liver function tests • • This signifies reduced organ perfusion This signifies reduced organ perfusion Oxygen saturation of venous blood • SVO2
Checking Lactate • Marker end organ perfusion • End product – anaerobic metabolism • Lactate >4 = panic value • Lactate normalisation
Using CVP • Poor evidence behind recommendations • 8-12mmHg is ideal range • >15 mmHg if ventilated • <8mmHg & hypotensive = fluids
Measuring IVC Full non-collapsing IVC = Pt adequately filled.
Fill the Tank
Fluid Resuscitation • Improve microvascular blood flow • Increase cardiac output • May benefit cardiogenic shock • Fluid maldistribution
What fluid & How Much? • Crystalloid –first choice • Albumin in certain patients! • Boluses 500ml-1tre every 20-30mins
Monitoring Fluid Resuscitation • ^ systemic arterial pressure • < heart rate • ^ urine output
When Fluids Fail
Vasoactive Agents • Used to optimise: • End-organ perfusion • Oxygen delivery
Inotrope(s) • Increase the force & velocity of myocardial contraction with increased contraction, stroke volume & cardiac output.
Inotropes • Examples: • Adrenaline • Dobutamine • Isoprenaline
Vasopressor(s) • Increase vascular tone with raised MAP & SVR.
Vasopressor(s) • Noradrenaline • Vasopressin • Dopamine
Push Dose Pressor • Short acting vasopressor that works through potent & selective alpha stimulation.
Push Dose Pressor • Metaraminol • Adrenaline • Ephedrine
The Hard Evidence! • No agent has shown to have superiority over any others in good quality studies!
Use Based On • Cost • Availability • Interpretation of physiology • Personal/physician preference • Institutional preference
Target Receptors • Alpha 1- vasoconstriction, ^ SVR • Alpha 2 – smooth muscle contraction • Beta 1 – positive chronotrope/inotrope, ^HR, ^contractility • Beta 2 – induce vasodilatation
CVC • Preferred • IVC till bridge to CVC
Do We Always Need CVC?
Indications • Fluid resuscitation = failed • Persistent hypotension • Improve contractility & cardiac output
Forget BP –Focus MAP • Mean arterial pressure MAP = CO x SVR • Target MAP >65mmHg • Chronic hypertension aim higher • Measure adequate tissue perfusion
Case 1 • What vasoactive medication is indicated?
Adrenaline • Alpha & beta adrenergic properties • Treats 3 aspects of anaphylaxis • Laryngeal oedema • Bronchospasm • Shock
Adrenaline Actions • Vasoconstriction • Reduction - mucosal oedema • Bronchodilation • Increased myocardial contractility
Case 1 • What dose and route would you give it?
Case 1 • Adult 0.3-0.5mg (1mg/ml) • IMI (lateral thigh) • Rpt as needed - consider infusion.
Case 2 • What vasoactive medication is indicated?
Noradrenaline • Surviving Sepsis Guidelines 2013 • Norad = vasoconstriction - HR + contractility. • 6mg 100mls or 3mg 50mls 5% Dextrose
Vasoactive's in Sepsis
Postintubation Hypotension • Occurs in 23% of ED intubations • Vasodilation of induction agents
Case 3 • What vasoactive medication is indicated?
Push Dose Pressors • Metaraminol 10mg/ml (mix in 20mls) • Sympathomimetic amine • increases systolic/diastolic BP • Short acting 3-10min
Cardiogenic Shock • Results from primary cardiac dysfunction • MI • papillary muscle/ventricular septal rupture, left ventricle dysfunction
Case 4 • What vasoactive medication is indicated?
Inotropes • Dobutamine • Beta 1 effects - cardiac contractility • Beta 2 effects - reduce afterload • Refractory consider adding Noradrenaline
Take Home Points • Shock/hypotension is common • Fluids often fail • Be familiar with indications, dose & pharmacology for vasoactive meds
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