vasopressors and inotropes
TRANSCRIPT
Vasopressors and Vasopressors and InotropesInotropes
Critical Care Lecture SeriesCritical Care Lecture Series
ICUObjectivesObjectives
What are the different classes of shock and What are the different classes of shock and give examples of each.give examples of each.
Discuss how to investigate and the Discuss how to investigate and the management principles behind each of the management principles behind each of the causes of shock.causes of shock.
What are the different crystalloids and What are the different crystalloids and colloids available for resuscitation?colloids available for resuscitation?
Have knowledge of the mechanism of Have knowledge of the mechanism of action of commonly used vasopressors and action of commonly used vasopressors and inotropes, including dopamine, inotropes, including dopamine, dobutamine, milnerone, levophed, dobutamine, milnerone, levophed, phenylephrine, epinephrine, vasopressinphenylephrine, epinephrine, vasopressin
Discuss adverse events associated with the Discuss adverse events associated with the above agents.above agents.
ICUIs My Patient in Shock?Is My Patient in Shock?
Definition of shockDefinition of shock Inadequate end organ perfusion Inadequate end organ perfusion
leading to inadequate oxygen leading to inadequate oxygen deliverydelivery
N.B. a patient in shock does not N.B. a patient in shock does not have to be hypotensivehave to be hypotensive
ICU
ICU
Treatment of ShockTreatment of Shock
Basic Resuscitation: Basic Resuscitation: ABCDE’sABCDE’s
A: Airway establishmentA: Airway establishment B: Breathing: control WOBB: Breathing: control WOB C(a): Circulation OptimizationC(a): Circulation Optimization C(b): Control O2 consumptionC(b): Control O2 consumption D: Delivery of O2 adequatelyD: Delivery of O2 adequately E Extraction of O2E Extraction of O2
ICUFluid resuscitationFluid resuscitation
Very important….Very important…. Therapy with least detrimental Therapy with least detrimental
effectseffects Fluid therapy may be beneficial Fluid therapy may be beneficial
in any type of shockin any type of shock Even cardiogenic shock/pulmonary Even cardiogenic shock/pulmonary
edemaedema
ICUFluid ResusitationFluid Resusitation
Must “test the patient”Must “test the patient” Give volume and look for Give volume and look for
response/improvementresponse/improvement Always start with NS of RLAlways start with NS of RL ? Need blood? Need blood
Must always look for the effect of Must always look for the effect of treatmenttreatment Re-evaluate patient after fluidRe-evaluate patient after fluid If no improvement, and no adverse effects, If no improvement, and no adverse effects,
repeatrepeat If adverse effect, needs inotropes/vasopressor If adverse effect, needs inotropes/vasopressor
if still in shockif still in shock Too much: pulmonary edema (OToo much: pulmonary edema (O22 sats) sats)
ICUA: Airway establishmentA: Airway establishment
Indications for intubation:Indications for intubation:
1. Failure of oxygenation or ventilation1. Failure of oxygenation or ventilation
2. Failure to protect airway2. Failure to protect airway
3. Condition present or procedure 3. Condition present or procedure needed that will require intubationneeded that will require intubation
““shock” is an indication for intubationshock” is an indication for intubation
Hypotension common after intubationHypotension common after intubation
ICU
B: Breathing: control B: Breathing: control WOBWOB
Respiratory muscles are Respiratory muscles are significant consumers of oxygensignificant consumers of oxygen
Control will allow better O2 Control will allow better O2 delivery to other tissuesdelivery to other tissues
Sedation after intubationSedation after intubation
ICU
C(a): Circulation C(a): Circulation OptimizationOptimization
Most causes of shock require Most causes of shock require some volume re-expansion – some volume re-expansion – even cardiogenic shock even cardiogenic shock
- Starling curve- Starling curve Crystalloid as good as colloidCrystalloid as good as colloid Vasopressors ineffective if Vasopressors ineffective if
hypovolemichypovolemic ““double edged sword”double edged sword”
ICU
C(b): Control O2 C(b): Control O2 consumptionconsumption
Reduce hyper-adrenergic stateReduce hyper-adrenergic state Analgesia/sedation/muscle Analgesia/sedation/muscle
relaxationrelaxation temperaturetemperature
ICU
D: Delivery of O2 D: Delivery of O2 adequatelyadequately
Follow sats (keep > 92%)Follow sats (keep > 92%) ? Transfusion (Hbg >80-100)? Transfusion (Hbg >80-100) LactateLactate SmvO2SmvO2
ICUE: Extraction of O2E: Extraction of O2
O2 must get from lungs to Hbg O2 must get from lungs to Hbg to tissuesto tissues
O2 extraction important in some O2 extraction important in some types of shocktypes of shock Cyanide, MetHbg, SEPSISCyanide, MetHbg, SEPSIS
ICU ABCDE’s: SummaryABCDE’s: Summary A: Airway establishmentA: Airway establishment: 02,biPap, ETT: 02,biPap, ETT
B: BreathingB: Breathing: control WOB: Sedation, analgesia: control WOB: Sedation, analgesia
C(a): Circulation OptimizationC(a): Circulation Optimization: fluids, inotropes, : fluids, inotropes, pressorspressors
C(b): Control O2 consumptionC(b): Control O2 consumption: sedation, temp : sedation, temp control, seizure controlcontrol, seizure control
D: Delivery of O2 adequatelyD: Delivery of O2 adequately: Hbg, fluid, pressor, : Hbg, fluid, pressor, inotropesinotropes
E: Extraction of O2E: Extraction of O2: R/O cyanide, metHbg, sepsis: R/O cyanide, metHbg, sepsis
ICUVasopressorsVasopressors
Many different pressors/inotropesMany different pressors/inotropes Need to understand how they work to Need to understand how they work to
use effectivelyuse effectively If choose wrong one, or use If choose wrong one, or use
inappropriately, can harm the patientinappropriately, can harm the patient Adrenergic precipitation of arrhythmiasAdrenergic precipitation of arrhythmias Drive the heart too fast resulting in Drive the heart too fast resulting in
decreased filling time and decreased stroke decreased filling time and decreased stroke volumevolume
Vasoconstriction of splachnic circulation Vasoconstriction of splachnic circulation and coronary arteriesand coronary arteries
Inotropes may make certain patients Inotropes may make certain patients hypotensivehypotensive
ICUVasopressorsVasopressors
ββ1 agonist/stimulation: 1 agonist/stimulation: chronitropic, inotropicchronitropic, inotropic
ββ2 agonist/stimulation: 2 agonist/stimulation: vasodilation, bronchodilationvasodilation, bronchodilation
αα: vasoconstriction: vasoconstriction D: increases renal blood flowD: increases renal blood flow
ICU Vasopressors and inotropes: the chart (everything you need to know)
Need CONeed CO Need nothingNeed nothing
Need BP Need BP and COand CO
Need BPNeed BP
Blood pressure
Cardiac Output
Low Normal
Low
Normal
ICUDopamineDopamine
Dopaminergic, Beta, Alpha: Dopaminergic, Beta, Alpha: ranges ?ranges ?
Dopa: 1-5 ug/kg/minDopa: 1-5 ug/kg/min ? Renal flow? Renal flow
Beta: 5-10 ug/kg/minBeta: 5-10 ug/kg/min Inoptropy/chronotropyInoptropy/chronotropy
Alpha: >10 ug/kg/minAlpha: >10 ug/kg/min VasoconstrictionVasoconstriction
Major use: increasing HR, ? bpMajor use: increasing HR, ? bp
ICUDobutamineDobutamine
Beta (little alpha)Beta (little alpha) Inotropic/chronotropicInotropic/chronotropic 2-20 ug/kg/min2-20 ug/kg/min Major use: Systolic dysfunctionMajor use: Systolic dysfunction Caveat: can/will decrease MAPCaveat: can/will decrease MAP
ICUMilrinoneMilrinone
Used as an inotropeUsed as an inotrope Mechanism of ActionMechanism of Action
Phosphodiesterase inhibitorPhosphodiesterase inhibitor decrease the rate of cyclic AMP degradationdecrease the rate of cyclic AMP degradation increase in cyclic AMP concentration leads to enhanced increase in cyclic AMP concentration leads to enhanced
calcium influx into the cell, a rise in cell calcium concentration, calcium influx into the cell, a rise in cell calcium concentration, and increased contractility and increased contractility
Side EffectsSide Effects can also cause vasodilatation but tends to have less can also cause vasodilatation but tends to have less
chronotropy than dobutaminechronotropy than dobutamine Onset of actionOnset of action
5-15 minutes 5-15 minutes DurationDuration
Half life of approximately 2 hours (so its gonna last a whileHalf life of approximately 2 hours (so its gonna last a while DoseDose
Loading dose: 50 mcg/kg administered over 10 minutes Loading dose: 50 mcg/kg administered over 10 minutes followed by 0.375 mcg/kg/minute followed by 0.375 mcg/kg/minute
ICUPhenylepherinePhenylepherine
Pure alpha agonistPure alpha agonist Vasoconstrictor with no effect on Vasoconstrictor with no effect on
inotropy/chronotropyinotropy/chronotropy 0.2-3.0 ug/kg/min0.2-3.0 ug/kg/min Major use: non-cardiogenic Major use: non-cardiogenic
hypotensionhypotension
ICUNorepinepherineNorepinepherine
Alpha and BetaAlpha and Beta 0.02-3.0 ug/kg/min0.02-3.0 ug/kg/min Major Use: when you need A&BMajor Use: when you need A&B
? Drug of choice for septic shock? Drug of choice for septic shock
ICUEpinepherineEpinepherine
Alpha and BetaAlpha and Beta 0.01 – 1.0 ug/kg/min0.01 – 1.0 ug/kg/min Major Use: when you need A&BMajor Use: when you need A&B
resuscitationresuscitation
ICU
Vasopressors and Vasopressors and inotropesinotropes
DobutamineDobutamine
MilrinoneMilrinonenothingnothing
DopamineDopamine
LevophedLevophed
EpinepherineEpinepherine
OrOr
Dobutamine/phenylDobutamine/phenyl
PhenylepherinPhenylepherinee
LevophedLevophed
(dopamine)(dopamine)
Blood pressure
Cardiac Output
Low Normal
Low
Normal
ICU
ICU
Overview of the Overview of the Management of ShockManagement of Shock
ICUCase StudyCase Study
65 yo male presents to ED65 yo male presents to ED Complaining of cough and feeling Complaining of cough and feeling
very unwellvery unwell HR 120, BP 100/60, RR 30, temp HR 120, BP 100/60, RR 30, temp
3939 Is this patient in shock?Is this patient in shock? What investigationsWhat investigations What treatment would you start?What treatment would you start?
ICU
The patient’s BP drops to 90/50, The patient’s BP drops to 90/50, what would you do now?what would you do now?
Would you start pressors? Which Would you start pressors? Which one?one?
Case StudyCase Study
ICUCase StudyCase Study
The patient is on 0.8ug/kg/min of The patient is on 0.8ug/kg/min of levophed through a femoral line. levophed through a femoral line. Why might the patient not be Why might the patient not be responding to the vasopressors? responding to the vasopressors? What measurement would be What measurement would be helpful in improving this man’s helpful in improving this man’s MAP?MAP?
ICUCase StudyCase Study
The patient has been The patient has been resuscitated, now has a BP of resuscitated, now has a BP of 110/90. HR 65. His JVP is 12. His 110/90. HR 65. His JVP is 12. His lactate continues to rise lactate continues to rise however. He is also anuric. Is this however. He is also anuric. Is this patient in shock? What is your patient in shock? What is your management now?management now?
ICUSummarySummary
Shock can be the consequence of Shock can be the consequence of decreased SVR, decreased CO or both. decreased SVR, decreased CO or both.
Management of shock should be Management of shock should be tailored to the physiologic state of the tailored to the physiologic state of the patient of the patient.patient of the patient.
Drugs are available to augment SVR, Drugs are available to augment SVR, HR, afterload and contractility. HR, afterload and contractility.
Remember to optimize preload and Remember to optimize preload and consider the oxygen carrying capacity consider the oxygen carrying capacity of the blood.of the blood.