Resuscitating the Hypotensive Patient

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Information about Resuscitating the Hypotensive Patient
Health & Medicine

Published on December 11, 2013

Author: kanegu

Source: slideshare.net

Description

A presentation for Emergency Nurses on Resuscitating Hypotensive Patients!

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

Invasive Monitoring

Forget BP –Focus MAP • Mean arterial pressure MAP = CO x SVR • Target MAP >65mmHg • Chronic hypertension aim higher • Measure adequate tissue perfusion

Case 1

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

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

Case 3

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

Case 4

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

Thankyou

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