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Vasopressors
What?
When?
Why?
Wprecautions?
Vasopressors
Definitions
Pressor: Increases blood pressure by
stimulating constriction of blood vessels
Definitions
Inotrope: Alters force or energy of
muscular contractions
Definitions
Shock: Inability of oxygen delivery to meet
tissue oxygen requirements
Pathophysiology
Cardiac output
Heart Rate
Sympathetic and
Parasympathetic tone
Circulating
chatecolamines
Preload
Changes in venous
return
Changes in plasma
volume
Contractility
Sympathetic tone
Circulating
catecholamines
Progression to Late
Septic Shock
Hypotension despite adequate fluid
resuscitation
Presence of hypoperfusion or organ
dysfunction
Acidosis / alteration in mental status
Hemorrhagic Shock
Rapid reduction in blood volume
Heart rate and blood pressure responses
can be variable
Vasopressors may be harmful if pt is
hypovolemic; Despite improvement in
blood pressure, renal blood flow
decreases and renal vascular resistance
rises
Cardiogenic Shock
Pump failure
Results when more than 40% of
myocardium damaged
Similar circulatory and metabolic changes
to hemorrhagic shock
Treatment
1. Fluids / Procedures
2. DRUGS!
Vasopressors
Inotropes
Fluid Requirements
There is no evidence-based support for
one fluid-type over another(surviving
sepsis)
Early fluid administration more important
than fluid type
HES/Albumin/Gelatin/LR; Rivers et al
Pharmacology
Pharmacology
Adrenergic System
Alpha adrenergic
Increases vascular tone
May decrease cardiac output
May decrease regional blood flow (renal, spleen,
cutaneous)
Beta adrenergic
Maintains blood flow
May increase cellular metabolism
May decrease immune system
Pharmacology
Dopaminergic
Vasopressors
Norepinephrine
Dopamine
Epinephrine
Vasopressin
Phenylephrine
Vasopressors
Phenylephrin
e
Vasopressors
Vasopressors
Vasopressin
Receptors
Receptors
Norepinephrine
Historically considered a poor choice in
shock due to excessive vasoconstriction
and end-organ hypoperfusion
This opinion began to change recently
Benefits: raise arterial pressure and
systemic vascular resistance
Maintain cardiac function / improve renal
function
Dopamine
More potential for arrhythmias/increased
heart rate
May increase both blood pressures and
flow; may be best used in patient with low
heart rate and inadequate fluid
resuscitation
Epinephrine
Epi often used as 3rd line after NE and DA
failed
Epi always first line in Anaphylactic Shock
Vasopressin
Vasopressin works on V1,V2,V3 receptors
Increases bp / may improve mortality
May decrease NE requirements
May improve renal function
Avoid in MI; in cardiac ischemia may
decrease contractility/lower CO/increase
mortality
At doses > 0.04 units/hr may decrease GI
blood flow
Studies
VASST
Studies
Martin: Norepi in Septic Shock
Martin et al
Patients receiving NE had best survival
rate on all days of hospital stay (p<0.001)
Mortality strongly associated with high
lactate and low urine output
NE was associated with a highly significant
decrease in hospital mortality. The data
contradict the notion that norepinephrine
potentiates end organ hypoperfusion through
excessive vasoconstriction
Studies
De Backer: Norepi v Dopamine in Shock.
DeBacker et al
Included Septic (62.2%), Cardiogenic
(16.7%), and Hypovolemic (15.7%) shock.
More patients in DA group required 2 nd
pressor
Subgroup: DA in cardiogenic shock
increased mortality significantly (p=0.03)
Conclusion: This study raised serious
concern about the safety of Dopamine
Practical Considerations
Vascular Access
Access to drug
Compatibilities
Titration
Adverse effects
Line
Must flush well
As big as possible
Preferred infusion site = forearm (basilic, cephalic, and
median antebrachial)
http://emcrit.org/podcasts/peripheral-vasopressors-extravasation/
Ricard JD, et al. Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Crit Care Med. 2013 Sep;41(9):2108-15
Extravasation
Drug
Dobutamine
Effect
Irritant; Rare reports of
vesicant effects
Dopamine,
Vesicants
Epinephrine,
Phenylephrine
Norepinephrine
, Vasopressin
Mechanism(s) of
tissue injury
Cytotoxicity, acidic
pH
Vasoconstriction
Extravasation
Phentolamine
Hypotensive patient
Recognize pressor needed
Physician orders
Order recognized in ORCA
Pharmacy technician makes drip
Pharmacist checks drip
Pharmacy technician tubes drip
Nurse collects from tube station
Nurse starts drip
Premixed and in
PYXIS!
Epinephrine,
Phenylephrine,
Norepinephrine,
Vasopressin
Mixed by technician
after order received in
inpatient pharmacy
Call pharmacy
Compatibilities
Variable Call pharmacy
Most likely to be compatible: Epinephrine,
dobutamine, dopamine, vasopressin
Maybe: Phenylephrine
Generally not tested: Norepinephrine
Titration
Starting a drip
MD must order
Generally best to start low and increase
Adverse effects frequently dose related
Adverse Reactions
Phenylephrin
Epinephrine Norepinephrine Dopamine Dobutamine Vasopressin e
Tachycardia
x
x
Arrhythmias
Increased
myocardial O2
x
demand
Decreased
perfusion to
x
vital organs
Nausea/vomitin
g
Metabolic
x
acidosis
High doses x
High doses x
x
x (ventricular)
x (less)
x
x
x
Hypersensitivity
Extravasation
x
(contains
sulfites)
x
References
De Backer D et al. Comparison of dopamine and norepinephrine in
the treatment of shock. N Engl J Med 2010;362:779-89.
Martin C et al. Effect of norepinephrine on the outcome of shock.
Crit Care Med 2000; 28:2758 2765
Perel A. The initial hemodynamic resuscitation of the septic patient
according to Surviving Sepsis Campaign guidelines does one size
fit all? Critical Care 2008, 12:223
Russel J. Vasopressin in the management of septic shock. Critical
Care 2011, 15:226
Russell JA, et al. Vasopressin versus norepinephrine infusion in
patients with septic shock. N Engl J Med 2008, 358:877-887.
Ricard JD, et al. Central or peripheral catheters for initial venous
access of ICU patients: a randomized controlled trial. Crit Care Med.
2013 Sep;41(9):2108-15