Shock and Vasopressors Nina E. Glass, MD TACS Fellow SICU Didactic Curriculum 9/24/14
Review Question Unilaterally diminished breath sounds A. Figure 1 B. Figure 2 C. Both D. Neither
Related Specialties 39
Review Question Jugular venous distension A. Figure 1 B. Figure 2 C. Both D. Neither
Review Question Muffled heart sounds A. Figure 1 B. Figure 2 C. Both D. Neither
Review Question Typically does not require operative intervention A. Figure 1 B. Figure 2 C. Both D. Neither
Review Question Which of the following statements about blunt cardiac injuries is TRUE? A. Echocardiography is indicated in patients with hemodynamic instability. B. Bradycardia is a common finding. C. Depressed ST segents on electrocardiogram are pathognomonic. D. Troponin levels should be monitored routinely for 24 hours. E. Chest pain is an indication for 12-24 hours of monitoring by telemetry.
Review Question A 70-year-old man is postoperative day 1 from an omental patch placement for a perforated duodenal ulcer. His lactate is 5 mmol/l, his blood pressure is 90/60 mm Hg, his heart rate is 90 beats per minute, his cardiac index is 2.4 L/min/m2, his pulmonary wedge pressure is 4 cm of H2O, and his central venous pressure is 1 cm of H2O. Which of the following statements is TRUE? A. He is in cardiogenic shock. B. He should be given a crystalloid fluid bolus. C. He should be started on a vasopressin drip. D. He should be started on a phenylephrine drip. E. He should be started on an epinephrine drip.
Review Quesiton A 70-year-old diabetic woman is admitted to the intensive care unit in septic shock after an open cholecystectomy for gangrenous cholecystitis. She has refractory hypotension despite aggressive fluid resuscitation and high-dose norepinephrine infusion. Which of the following vasopressive agents is most appropriate to start in this patient? A. Phenylephrine B. Vasopressin C. Ephedrine D. Midodrine E. Dopamine
Review Question A 26-year-old man is transported to your hospital after a skiing accident. Chest and pelvis radiographs at the outside hospital are normal, but his lateral cervical spine film shows a subluxation at C6-7. He is alert, responsive, and not hypoxic. On physical exam, he has no sensation or movement beneath the clavicles, no rectal tone, and evidence of priapism. Despite 2-L crystalloid infusion, he has a blood pressure of 75/40 mm Hg and a pulse of 85 beats per minute. Which of the following is the next most appropriate step in this patient s management? A. Norepinephrine infusion B. Dopamine infusion C. CT scan of the spine, chest, abdomen, and eplvis D. MRI of the cervical and thoracic spine E. Focused assessment with sonography for trauma (FAST) exam
Review Question A 20-year-old woman is involved in a motor vehicle crash and is unable to move her extremities on admission to the emergency department. She is initially hypotensive but responds to fluid administration. CT scans reveal a cervical spine subluxation injury at C5-C6. Her only other injury is a nondisplaced pubic ramus fracture. No other injuries are seen on the scans of her head, chest, abdomen, and pelvis, and she has no long bone fractures or significant soft tissue injuries. When she arrives at the intensive care unit, her blood pressure falls to 80/50 mm Hg with a pulse of 55 beats per minute and O2 saturation of 99%. With further volume resuscitation, her O2 saturation falls to 88%, but her other vital signs do not change. Pulmonary auscultation reveals rales. Her extremities appear wellperfused with brisk capillary refill. Which of the following is the best treatment for her hypotension? A. Exploratory laparotomy B. Pelvic wrap C. Steroids D. Pressors E. Blood products in a 1:1:1 ratio (red cells:plasma:platelets)
Pharmacotherapy in shock Vasopressors Norepinephrine Epinephrine Dopamine Phenylephrine Inotropes Dobutamine Dopexamine Isoproterenol Milrinone Levosimendan Miscellaneous Vasopressin Terlipressin Steroids (Drotrecogin Alfa)
Overview of pharmacotherapy Goals of therapy: Raise blood pressure Raise heart rate Improve cardiac output Improve tissue perfusion Side effects of therapy Arrhythmias Vasoconstriction
Vasopressors
Norepinephrine Naturally occurring Potent α-adrenergic effects Less potent β 1 stimulation Indications First line treatment in septic shock May be used for acute hypotension from any cause Moderately arrhythmogenic Peripheral vasoconstriction Leave em Dead Enhances renal function in sepsis
Review Question A 54-year-old woman is undergoing a lumpectomy and sentinel node biopsy. Shortly after induction, while the surgeon is injecting isosulfan blue into the breast, the patient becomes hypotensive and flushed, and she becomes difficult to ventilate. From the following agents that the patient received, which is most likely to be the cause of the anaphylactic reaction? A. Isosulfan blue B. Succinylcholine C. Propofol D. Cefazolin E. Lidocaine
Epinephrine Major physiologic adrenergic hormone of the adrenal medulla Potently stimulates α 1 receptors Β effects (1 and 2) Chronotropic and inotropic Vasodilation less MAP than Norepinephrine Dose-dependent response Indications Anaphylaxis (β 2 blunts mast cell response) Cardiac arrest/other refractory conditions
Dopamine Hormone precursor of norepinephrine and epinephrine Dose dependent α, β, and dopaminergic receptors Renal dose, 0-5μg/kg/min, dopa Middle dose, 5-10μg/kg/min, β High dose, 10-20μg/kg/min, α Arrhythmogenic (particularly lower doses) Indications...
Review Question Therapy for a 30-year-old intubated man after fall from 20 feet who is in the intensive care unit with pelvic and thoracic spine fractures, flaccid, warm bilateral lower extremities, bradycardia, hypotension, and negative thoracic, abdominal, and pelvic computed tomography. A. Intravenous dobutamine B. Intravenous phenylephrine C. Transfusion packed red blood cells D. Intravenous corticosteroids E. Intravenous antibiotics
Phenylephrine Rapid/short duration Pure α 1 stimulation Increases SVR to increase MAP Reflex bradycardia Impairs cardiac output by increasing afterload Indications Distributive shock with tachyarrhythmia Pregnant patient with shock
Review Question Selective alpha-1 adrenergic receptor agonist, potent vasoconstrictor A. Norepinephrine B. Epinephrine C. Phenylephrine D. Vasopressin E. Dobutamine
Review Question Alpha and beta-1 adrenergic receptor agonist, used in septic shock A. Norepinephrine B. Epinephrine C. Phenylephrine D. Vasopressin E. Dobutamine
Review Question Alpha, beta-1, and beta-2 receptor agonist, produced in the adrenal medulla A. Norepinephrine B. Epinephrine C. Phenylephrine D. Vasopressin E. Dobutamine
Inotropes
Dobutamine Synthetic adrenergic agent L-isomer α 1 ; D-isomer β 1 /β 2 Indications Pulmonary edema with marginal blood pressure
Dopexamine Synthetic catecholamine Dopa/Β 2 >>β 1 causing vasodilation and positive inotropy via afterload decrease; also inhibits Norepi reuptake Improved splanchnic perfusion Indication Compared to dobutamine/dopamine
Isoproterenol Pure β agonist May lead to cardiac ischemia Indications β-blocker overdose Atropine-resistant transplanted heart
Milrinone Synthetic phosphodiesterase III inhibitor Increases camp Modulates myocardial contractility Vasodilation Indications Cardiogenic shock/cardiac failure Acutely decompensated CHF
Levosimendan Increases sensitivity of troponin C for calcium without enhancing nflux of calcium Indications Currently used perioperatiely in cardiac surgery patients Under investigation for use in septic shock, etc.
Other pharmacologic therapy
Vasopressin Hormone V1 receptors Indications Septic shock (adjunct to norepinephrine) ACLS (along with steroids)
Terlipressin Analogue of vasopressin Long half life
Review Question Therapy for a 55-year-old woman with severe rheumatoid arthritis in the intensive care unit with tachycardia, hypotension, and fever after recent negative exploratory laparotomy. A. Intravenous dobutamine B. Intravenous phenylephrine C. Transfusion packed red blood cells D. Intravenous corticosteroids E. Intravenous antibiotics
Steroids Indications Stress-dose steroids Adrenal insufficiency
Drotrecogin Alfa Recombinant Activated protein C Down-regulates proinflammatory state (including anticoagulant/enhance fibrinolysis/opens microcirculation) Off market
In Summary, a few recommendations...
Recommendations (1) Smaller combined doses of inotropes and vasopressors may be advantageous over a single agent used at higher doses to avoid doserelated adverse effects. Christopher B. Overgaard and Vladimír Džavík. Inotropes and Vasopressors. Circulation; Volume 118(10):1047-1056. September 2, 2008
Recommendations (2) The use of vasopressin at low to moderate doses may allow catecholamine sparing, and it may be particularly useful in settings of catecholamine hyposensitivity and after prolonged critical illness. Christopher B. Overgaard and Vladimír Džavík. Inotropes and Vasopressors. Circulation; Volume 118(10):1047-1056. September 2, 2008
Recommendations (3) In cardiogenic shock complicating AMI, current guidelines based on expert opinion recommended dopamine or dobutamine as first-line agents with moderate hypotension (systolic blood pressure 70-100 mm Hg) and norepinephrine as the preferred therapy for severe hypotension (systolic blood pressure Christopher <70 B. Overgaard mmhg). and Vladimír Džavík. Inotropes and Vasopressors. Circulation; Volume 118(10):1047-1056. September 2, 2008
Recommendations (4) Routine inotropic use is not recommended for end-stage heart failure. When such use is essential, every effort should be made to either reinstitute stable oral therapy as quickly as possible or use destination therapy such as cardiac transplantation or LV assist device support. Christopher B. Overgaard and Vladimír Džavík. Inotropes and Vasopressors. Circulation; Volume 118(10):1047-1056. September 2, 2008
Recommendations (5) Large randomized trials focusing on clinical outcomes are needed to better assess the clinical efficacy of these agents. Christopher B. Overgaard and Vladimír Džavík. Inotropes and Vasopressors. Circulation; Volume 118(10):1047-1056. September 2, 2008
Surgical Critical Care I.36 Phosphodiesterase inhibitor A. Phenylephrine B. Fenoldopam C. Amrinone D. Vasopressin E. Nitroglycerin
Surgical Critical Care I.37 Pure alpha-agonist A. Phenylephrine B. Fenoldopam C. Amrinone D. Vasopressin E. Nitroglycerin
Surgical Critical Care I.38 Antidiuretic A. Phenylephrine B. Fenoldopam C. Amrinone D. Vasopressin E. Nitroglycerin
Surgical Critical Care I.39 Dopaminergic receptor agonist A. Phenylephrine B. Fenoldopam C. Amrinone D. Vasopressin E. Nitroglycerin
Surgical Critical Care I.40 Venodilator A. Phenylephrine B. Fenoldopam C. Amrinone D. Vasopressin E. Nitroglycerin
Surgical Critical Care II.38 Potent alpha-adrenergic activity; no affinity for beta-adrenergic receptors; minimal direct effect on heart rate A. Dopamine B. Dobutamine C. Norepinephrine D. Epinephrine E. Phenylephrine
Surgical Critical Care II.39 Affinity for both beta-1 and beta-2 adrenergic receptors; mild vasodilator effects A. Dopamine B. Dobutamine C. Norepinephrine D. Epinephrine E. Phenylephrine
Surgical Critical Care II.40 Dose-dependent alpha- and betareceptor affinity; increases cardiac contractility and heart rate A. Dopamine B. Dobutamine C. Norepinephrine D. Epinephrine E. Phenylephrine
Summary