vasopressor & inotropes

7/25/2019 vasopressor & inotropes

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Basic

LifeSupport

VASOPRESSOR & INOTROPES

IN SHOCK IMBIBE IT & APPLY

IT

VASOPRESSOR & INOTROPES

IN SHOCK IMBIBE IT & APPLY

IT

DR.S.ARUNKUMAR M.D(EM), PG.DIP.(USG),FELL!S"IP IN

IN#ENSI$E %ARE MEDI%INE & E%"%ARDIGRAP"'

EMERGEN%' & %RI#I%AL %ARE P"'SI%IANAS"!INI SPE%IALI#' "SPI#AL,SLAPUR

DR.S.ARUNKUMAR M.D(EM), PG.DIP.(USG),FELL!S"IP IN

IN#ENSI$E %ARE MEDI%INE & E%"%ARDIGRAP"'

EMERGEN%' & %RI#I%AL %ARE P"'SI%IANAS"!INI SPE%IALI#' "SPI#AL,SLAPUR


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Structure of ta*+Structure of ta*+

What is in your hand ?

Various receptors & its effect

Drugs Heroic & villain character

Clinical approach to cardiogenic & septic shock

Studies quoting what you should use & what you shouldnot

eco!!endations

"rou#leshooting during ad!inistration


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$asoacti-e ae/ts$asoacti-e ae/ts


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LifeSupport

So,what are theadrenergic

receptors & how

does it efect on?


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#"ER SPE%IFI% RE%EP#RS#"ER SPE%IFI% RE%EP#RS

DPAMINE RE%EP#RS

Present in the renal,

splanchnic, coronary,

cerebral & vascular beds. Sti!ulation of these

receptors leads to

vasodilation$

Second su#type of

dopa!ine receptors causesvasoconstriction #y inducing

norepinephrine release at

doses %'!cg(kg(!t

$ASPRESSIN RE%EP#RS


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LifeSupport

Pri/cip*es f Use f

$asopressors a/0 I/otropes

Pri/cip*es f Use f

$asopressors a/0 I/otropes

Hypotension !ay result fro!) "po-o*eia

Pup fai*ure

Pat1o*oic a*0istri2utio/ of 2*oo0 f*o3

Vasopressors are indicated for) Decrease of 456 "7869 fro 2ase*i/e

SBP or

MAP :;6 " a/0 E-i0e/ce of e/0ora/ 0sfu/ctio/ 0ue to

1poperfusio/

Hypovole!ia !ust #e corrected first


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Epi/ep1ri/eEpi/ep1ri/e

Dose &0i*utio/

Dose ) *+'!cg(!t

,'$-!cg(kg(!t #eta

effects

%'$-!cg(kg(!t+ alpha

effects

.C/S 0+-1!cg(!t

2ntratracheal dose *+*$1ti!es 2V dose

Dilution ) 3!g(*1'!l

Dose of '$*!g(kg CC4

or 44 overdose

%op*icatio/s

"achyarrhyth!ia

/eucocytosis

.ngina & 2ncreases!yocardial o5ygen

de!and

/actic acidosis

Dec renal & splanchnic#lood flow

Hypertension &

pul!onary ede!a


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BasicLifeSupport

Nor epi/ep1ri/eNor epi/ep1ri/e

Dose & Di*utio/

Dose ) *+'!cg(!t

.C/S 0+-1!cg(!t

Dilution 3!g(*1'!l Nora0re/a*i/e 2itartrate 8

(/ora0re/a*i/e 2ase


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Dopai/eDopai/e

Dose & Di*utio/

Dose )

'$1+1!cg(kg(!t+

vasodilation 1+'!cg(kg(!t cardiac

sti!ulation7.C/S9

%'!cg(kg(!t+

vasoconstriction


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BasicLifeSupport

Do2utai/eDo2utai/e

Dose & Di*utio/

:redo!inantly #eta

effects 7#eta%#eta*9

:otent2notropic(chronotropic

Dose ) *+*' !cg(kg(!in

=a5) 3'!cg(kg(!t

Dilution )*1'!g(*1'!l =a@or use) Systolic

dysfunction

%op*icatio/s

"achyarrhyth!ia &

ventricular ectopy

2ncreases !yocard >*de!and

Aever & headache

Dyspnoea

Can decrease =.: involu!e depleted patients

>ccasional B2 stress


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$asopressi/$asopressi/

Dose & 0i*utio/

Dose :0.01-0.04

units/minute

Dilution :1unit/ml Doses >0.04 units/mt

causes !" & !ardiac

ischemia

pressor e##ects preserved

durin$ hypo%ic and acidotic

conditions

=ay restore C:: after cardiac

arrest without producing

tachycardia

%op*icatio/s

.#d cra!ping8 nausea8

vo!iting

4ronchoconstriction

2ncr liver eny!es

=esentric ische!ia

Venous thro!#osis

Chest pain & =2

Decrease platelets

lactic acidosis

Water into5ication


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BasicLifeSupport

I/0icatio/ of -asopresssi/I/0icatio/ of -asopresssi/

Hyper+dyna!ic catechola!ine+resistant

vaso+plegic state

6ot as late rescue therapy in severe

refractory shock


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BasicLifeSupport

R"'#"M F DRUGS N

ALP"A & BE#A A%#I$I#'

R"'#"M F DRUGS N

ALP"A & BE#A A%#I$I#'

stro/est

NR

EPINEP"RINE =EPI

NEP"RINE 4DPAMINE4 P"EN'LEP"RINE!EAKES#

EPI

NEP"RINEDPAMINE

NR

EPINEP"RINE4 4

BE#A A%#I$I#'

ALP"A

A%#I$I#'


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#ac1p1*a>is#ac1p1*a>is

esponsiveness to these drugs can decreaseover ti!e due to tachyphyla5is

Doses !ust #e constantly titrated to ad@ust for

this pheno!enon & for changes in patient clinical

condition

How to counteract addition of second line drug

earlier

ioavailability o# subcutaneous heparin or insulin can

be reduced durin$ treatment 'ith vasopressors due

to cutaneous vasoconstriction$


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%*i/ica* Approac1 to s1oc+e0 patie/t%*i/ica* Approac1 to s1oc+e0 patie/t

!1at is s1oc+ ?De#ined by circulatory insu##iciency that creates an imbalance

bet'een the tissue o%y$en supply(delivery) & o%y$en demand

(consumption) 'ith multitude o# or$an dys#unction .

"eo0/aic paraeters Criteria for hypotension drop in sys$ 4:% -'!!hg fro! #aseline or

,E'(F'!!hg or =.: ,F'!!hg

Hypotension does not equate to shock often

Shock Oftenhappens prior to hypotension

Shock !ay happen despite nor!al 4: & conversely 4: !ay #e low

without shock #eing present


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Syste!ic "issue :erfusion

Cardiac >utput7C>9

Heart ate7H9

StrokeVolu!e

7SV9

:reload .fterload Contractility

Syste!ic Vascularesistance 7SV9


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Differe/tiatio/ of s1oc+Differe/tiatio/ of s1oc+

%ar0ioe/ic "po-o*eic Septic

Pu*se pressure G G

Diasto*ic pr G G GGG

E>treities Cool Cool War! initially8 coollater

Nai*e0 2*oo0retur/ Slow Slow apid

@$P G G

Respirator creps III ++ ++

S5 S Ga**op III ++ ++

%1est ra0iorap1 /arge heart8pul!onary ede!a

Di!inished cardiacsie

6or!al8unlesspneu!onia present

I0e/tifie0 site ofi/fectio/

++ ++ III


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%ar0ioe/ic s1oc+%ar0ioe/ic s1oc+

evasculariation i!!ediately is the definitivecare 7TIME IS MUSCLE 9

62V support 7when he!odyna!ically sa#le &

cooperative 9 =echanical ventilation even in nor!al

o5ygenation status with resp distress7to unload

resp$ !uscle workload9 & utiliation of low C>

#y vital organs 2nitial therapy of hypotension

A//


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%ARDIGENI% S"%K ? Approac1%ARDIGENI% S"%K ? Approac1

V 26A.C" W2"H HJ:>";6S2>6

Aluid #olus *1'+1''=/ 7over '+1!inutes9

.6"$W.// 26A.C" W2"H HJ:>";6S2>6 Aluid challenge ''+*1'=/7over '+1!inutes9

Static test

Clinical end points7H 4: vein

co!pressi#ility urine output9

CV::CW:CK:2CC>

D/aic testi/

:assive leg raise testing7pulsepressure variation9

;nd e5piratory occlusion

testing

*cho & + o# ! diameter


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BasicLifeSupport

%ar0ioe/ic s1oc+%ar0ioe/ic s1oc+

6>.D;6./26; S" L 1=CBS(="7-$0=/(H92A 4:,0'==HB


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"aper & stop inotropic supports7dopa!ine & do#uta!ine 9 if4: i!proved % #aseline level for that patient(=.: %F1!!hg

"aper noradrenaline once reached 1!cgs(!t dosage

IF BP N# IMPR$ED

Start

EPINEP"RINE( c7t )

Uptitrate to a>iu EPINEP"RINE ? 56cs7t

%$% LINE $asopressors & i/otropic supports 48;1ours71i1 0oses

SI#E ? I@$ (# MNI#R %$P )

AR#ERIAL LINE Epi/ep1ri/e 7 Nora0 4


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Ne3er Sepsis 0efi/itio/86


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Seue/tia* ora/ fai*ure assesse/t(SFA Score)Seue/tia* ora/ fai*ure assesse/t(SFA Score)


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SEP#I% S"%KSEP#I% S"%K

Secure the air3a & 2reat1i/ + septic shock patient

F*ui0 resuscitatio/ + wide #ore 7F B9+ *'+3'!l(kg

crystalloids over -'+F' !inutes with careful vitals !onitoring

RES%UE P#IMIA#IN S#ABILIA#IN DEES%ALA#IN

Rescue 1''!l #olus over 1!inutes(FLUID BOLUS)

ptiiatio/ ''+*''!l over 1+' !inutes(FLUID CHALLENGE)

no longer life threatening8 to opti!ise tissue perfusionSta2i*iatio/ !aintenance fluids for ongoing nor!al fluid loss in

renal8B28 insensi#le loss

Deesca*atio/ stage of negative fluid #alance if warranted #y signs

& sy!pto!s


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FLUID ADMINIS#RA#INFLUID ADMINIS#RA#IN

#ARGE#S IN FLUID #"ERAP'

:ulse volu!e8 o5i!etry 8=.: %F1!!hg & :ulse

pressure variation

"arget CV: N+'c!7non ventilated9( '+*c! H*>7ventilated 9


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$ASPRESSR & IN#RPES ?

SEP#I% S"%K

$ASPRESSR & IN#RPES ?

SEP#I% S"%K

Which Vasopressors to start withOOOOOOOOO

6>+;:26;:H26; ?

D>:.=26; ?

D>42C; ?

o, hich dru$ as second line/rescue therapy


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S"%Ke0 HS"%Ke0 H6>.D;6./26; S" L 1=CBS(="7-$0=/(H9

2A 4:,0'==HB


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t "aper vasopressin L '$1units(hour

2f =.: % F1!!hg

%$% LINE $asopressors & i/otropic supports 48;1ours71i1 0oses

AR#ERIAL LINE $asopressi/ i/0icatio/ 7 Nora0 4"2C>S";>2DS

.DP


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' N# DPAMINE INS#EAD F NRAD' N# DPAMINE INS#EAD F NRAD


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Stu0iesStu0ies


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Stro/ recoe/0atio/sStro/ recoe/0atio/s

Cardiogenic shock + 6orepinephine as first line vasopressor

6orepinephrine stline vasopressor agent for septic shock

Do#uta!ine 2n septic shock for low cardiac output state despite volu!eresuscitation

;pinephrine infusion anaphylactic shock not responding to 2= or 2V #olusepinephrine

;pinephrine is the stline agent in hypotension after C.4B$

6or epinephrine stline vasopressor for undifferentiated shock notresponding to fluid therapy


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%o/0itio/a* recoe/0atio/s%o/0itio/a* recoe/0atio/s

Cardiogenic shock do#uta!ine ad!inistration if inotropedee!ed necessary

outine vasopressor use in hypovole!ic shock notreco!!ended

Vasopressin for he!orrhagic or hypovole!ic shock ifvasopressor dee!ed necessary

Qnown or suspected H>C= or dyna!ic outflow o#structionpts avoid inotropic agents $use vasopressors @udiciously


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%o/0itio/a* recoe/0atio/s%o/0itio/a* recoe/0atio/s

>#structive shock not reponding to specifiedtreat!ent8vasopressor should #e initiated

Vasopressin catechola!ine refractory septic shock

6orad stchoice for distri#utive shock due to hepaticfailure

Short ter! vasopressor infusion ,+*hours throughperipheral line co!plications unlikely


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#rou2*es1ooti/7%1ec+*ists 0uri/

I/otropes & Pressors support

#rou2*es1ooti/7%1ec+*ists 0uri/

I/otropes & Pressors support

2s the patient appropiately !onitored

Had the early use of vasopressors falsely elevated CV: & !asked hypovole!ia

.re the vasopressors !i5ed in correct dose

Vasopressor(inotropes & fluid tu#ing connected in separate line

Check out whether three way port directed properly for flow

624: intervals kept every '!inutes(2nvasive !onitoring .+line positioned( flushedqhour

Cardiac !onitors connected properly for specific patients

:rior filled pressor agents #efore ongoing supports e!pty

Drug na!e(Concentration & colour code la#elling of the various line done


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#a+e 1oe poi/ts#a+e 1oe poi/ts

$asopressi/ ? co/trai/0icate0 i/ %%F pts.(3ater rete/tio/ & se0after*oa0 )

$asopressi/ 2o3e* isc1eia & *actic aci0osis

I/otropes & -asopressor 3o/t 3or+ i/ aci0ic state( p" :.< )

I/otropes receptor 2i/0i/ affi/it a*tere0 2 teperature &co/ce/tratio/

%*assica* i/0icatio/ of so0a 2icar2 ? p":.< to a+e pressors

3or+

Do /ot i-e so0a 2icar2 i/ case of *actic aci0osis

E*e-ate0 *actate ? ar+er of ipaire0 o>e/ 0e*i-er7uti*iatio/


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REFEREN%ESREFEREN%ES

42"2SH P>A .6.;S"H;S2. C.6.D2.6 P>A ;=;B;6CJ =;D2C26;

>Q >A ;=;B;6CJ =;D2C26;

.=;2C.6 :H.=C2S" .SS>C2."2>6 C2"2C./C.; D>Q

:C2;"J >A 26";6S2V; C.;

=;D2C26; 2SCC= P>


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vasopressor & inotropes