Vasopressors and Inotropes in Canadian

Emergency Departments

Dennis Djogovic MD, FRCPC

Financial Disclosures

None to declare

ER docs treat shock

There are no evidence based guidelines to assist in which pressor/trope to use in shock

VICE has created a document to address thatCAEP standards committeeCJEM

VICE squad

Shavaun MacDonald Rob Green

Andrea Wensel Osama Loubani

James Lee Patrick Archambault

Janeva Kircher Simon Bordeleau

Katherine Smith Adam Szulewski

Jon Davidow Sara Gray

Dennis Djogovic Jean Marc Benoit

David Messenger

Dan Howes

What is Shock?

What are the types of shock?

Cardiogenic

Obstructive

Distributive

Hypovolemic

What are vasopressors?

Systemic vasoconstriction

Pulmonary vasoconstriction

Increase Mean Arterial Pressure (MAP)

What are inotropes?

Agents that increase cardiac output Increase inotropy Increase chronotropyDecrease afterload

Inotropes Vasopressors

Intra aortic Balloon Pump Phenylephrine

Dobutamine Ephedrine

Isoproteronol Norepinephrine

Epinephrine

Dopamine

Milrinone

Nitroprusside

Digoxin

Different shock types need different managment

Guidelines based on different shock types

Research methodology (only one slide!)

AGREE II

PICO questions

Section authors/literature review

GRADEQuality of evidenceStrength of recommendation

Delphi consensus process

88 530 articles identified

1040 articles in focused article list

113 articles used for grading purposes

7 clinical questions

18 recommendations5 strong13 conditional

Quality of Evidence

A= High Level of evidence Good RCT

B= Moderate Poor RCT, well done observational series

C= low Poor observational series

D= very low Case series, expert opinion

Strength of Recommendation

Balance desirable and undesirable effects

Quality of evidence

Values and preferences

costs

Strength of Recommendation

Strong

Conditional

70% of votes needed for “Strong” recommendation

Question 1: For ED patients in shock, what are the side effects of vasopressors and inotropes?

Dopamine increases the risk of tachyarrhythmia compared to norepinephrine. (Grade A).

Dopamine use in septic shock increases mortality compared to norepinephrine (Grade B).

Vasopressin as a first line vasopressor may be associated with cellular ischemia and skin necrosis, particularly when combined with sustained moderate to high dose infusions of norepinephrine. (Grade C).

Epinephrine increases metabolic abnormalities compared to norepinephrine. (Grade A).

Epinephrine increases metabolic abnormalities compared to norepinephrine-dobutamine in cardiogenic shock without acute cardiac ischemia. (Grade B).

Question 2: Which vasopressors and inotropes should be used in the treatment of ED patients with cardiogenic shock?

Recommendation: Cardiogenic shock patients in the ED should receive norepinephrine as the first-line vasopressor. (Strong)

Question 2: Which vasopressors and inotropes should be used in the treatment of ED patients with cardiogenic shock?

Recommendation: Cardiogenic shock patients in the ED should receive dobutamine if an inotrope is deemed necessary. (Conditional)

Question 3: Which vasopressors and inotropes should be used in the treatment of ED patients with hypovolemic shock?

Recommendation: Routine vasopressor use in hypovolemic shock is not recommended. (Conditional)

Recommendation: Vasopressin may be indicated in hemorrhagic or hypovolemic shock if a vasopressor is deemed necessary. (Conditional)

Question 4: Which vasopressors and inotropes should be used in ED patients with obstructive shock?

Recommendation: In obstructive shock not responding to indicated treatment, a systemically active vasopressor should be instituted.  (Conditional)

Question 4: Which vasopressors and inotropes should be used in ED patients with obstructive shock?

Recommendation: For patients with known or suspected hypertrophic obstructive cardiomyopathy (HOCM) or dynamic outflow obstruction, inotropic agents should be avoided. Judicious use of vasoconstrictive agents can be considered. (Conditional)

Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?

Recommendations: Norepinephrine is the first line vasopressor for use in septic shock. (Strong)

Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?

Recommendation: Vasopressin should be considered in catecholamine refractory septic shock. (Conditional)

Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?

Recommendation: Dobutamine should be used for septic shock with low cardiac output despite adequate volume resuscitation. (Strong)

Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?

Recommendation: Vasopressor choice in neurogenic shock is not clear. The agent should be determined by patient characteristics and response to treatment. (Conditional)

Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?

Recommendation: Norepinephrine is the first line agent for the management of distributive shock due to hepatic failure. (Conditional)

Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?

Recommendation: Epinephrine infusion is the preferred agent for anaphylactic shock that does not respond to intramuscular or intravenous bolus epinephrine. (Strong)

Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?

Recommendation: Vasopressor choice in distributive shock secondary to adrenal insufficiency not responding to steroid replacement is not clear. Patient response to chosen agents should guide therapy. (Conditional)

Question 6: Which vasopressors and inotropes should be used in ED patients with undifferentiated shock?

Recommendation: In undifferentiated shock not responding to fluid resuscitation, norepinephrine should be the first-line vasopressor. (Strong)

Question 6: Which vasopressors and inotropes should be used in ED patients with undifferentiated shock?

Recommendation: In undifferentiated shock, a second vasopressor should be added if a goal MAP>70mmHg is not being achieved. (Conditional)

Question 7: How should vasopressors and inotropes be administered to ED patients?

Recommendation: Short term vasopressor infusions (<1-2 hours) or boluses via properly positioned and functioning peripheral intravenous catheters are unlikely to cause local complications. (Conditional)

Question 7: How should vasopressors and inotropes be administered to ED patients?

Recommendation: Vasopressor infusions for prolonged periods (>2-6 hours) should preferentially be administered via central venous catheters. (Conditional)

Question 7: How should vasopressors and inotropes be administered to ED patients?

Recommendation: Inotropes can be given via peripheral catheter (short term) or central venous catheters (prolonged period) with a similarly low incidence of local complications. (Conditional)

Question 7: How should vasopressors and inotropes be administered to ED patients?

Recommendation: The administration of vasopressors via intra-osseous lines is safe in adults. (Conditional)

Question 7: How should vasopressors and inotropes be administered to ED patients?

In summary

Identify the type of shock To determine the type of treatment

Norepi > dopamine

Cross your fingers!