Vasopressors and inotropes in septic-shock: evidence based review

Dr Nabeel Senior resident Department of CCM SGPGIMS, Lucknow

SEPSIS

Overview
Introduction Definition of shock Types of shock Septic shock Receptor physiology Vasopressors and inotropes Literature review Conclusion

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Shock
Impaired tissue perfusion Reduced oxygen delivery Reduced nutrient delivery Inadequate cellular function
OXYGEN SUPPLY

OXYGEN DEMAND

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Definition of shock
Shock is a clinical syndrome characterised by:

Hypotension:
(SBP < 90 mmHg or MAP < 60 mmHg)

Oliguria:
(urine output < 20 mL/hr or 0.3 ml/kg/hr for 2 consecutive hours)

Poor peripheral perfusion:

(altered consciousness, cool and clammy skin, poor capillary refill, hyperlactetemia > 2mmol/L, metabolic acidosis)

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Types of Shock
Hypovolemic Cardiogenic Neurogenic Obstructive Distributive Septic

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SEPTIC SHOCK

Sepsis
Severe Sepsis
SEPTIC SHOCK

INFECTION

SIRS

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Septic shock
Sepsis with hypotension despite adequate fluid resuscitation, associated with hypoperfusion abnormalities.

3 major pathophysiological effects:

Vasodilatation (Vasoplegia) Maldistribution of blood flow Myocardial depression (Septic cardiomyopathy)

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Hemodynamic management of septic shock:

Fluid resuscitation Maintenance of adequate systemic pressure for optimal tissue perfusion
Animal studies suggest that below a MAP of 60 mm Hg, autoregulation in coronary, renal, and CNS vascular beds is compromised, and flow may become linearly dependent on pressure. Bersten AD 1995, Pflugers Arch 1987 In septic shock, MAP should be maintained > 60-65 mm Hg. Higher blood pressure targets may be warranted in some patients.

Optimizing LV dysfunction by inotropic agents

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Vasopressors
Dopamine Noradrenaline Vasopressin Terlipressin Epinephrine Phenylephrine

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Inotropes
Dopamine Dobutamine Dopexamine Phosphodiesterase inhibitors

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VAAST TRIAL

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Level of evidence for vasopressors in septic shock

Level 1
Low dose dopamine should not be used for renal protective effects

Level 2
Maintain MAP 65 mm Hg or as needed to achieve adequate endorgan perfusion(cerebral perfusion pressure, abdominal perfusion pressure, urine output) Norepinephrine is the first line agent when vasopressors are indicated. Epinephrine, phenylephrine, and vasopressin should not be used as first line agents If hypotension persists despite the use of norepinephrine, epinephrine should be added to current vasopressor therapy

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 Dobutamine may be initiated in combination with norepinephrine in patients with myocardial dysfunction (elevated cardiac filling pressures, low cardiac output) Vasopressin may be added to norepinephrine to optimize the therapeutic efficacy of norepinephrine

Level 3
None

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Surviving sepsis guidelines 2008

Vasopressors:
Maintain MAP 65mmHg. (1C) In patients requiring vasopressors, insert an arterial catheter as soon as practical. (1D) Norepinephrine or dopamine centrally administered are the initial vasopressors of choice. (1C) Epinephrine, phenylephrine or vasopressin should not be administered as the initial vasopressor in septic shock. (2C) Vasopressin 0.03 units/min maybe subsequently added to norepinephrine with anticipation of an effect equivalent to norepinephrine alone. (2B) Do not use low-dose dopamine for renal protection. (1A)

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Surviving sepsis guidelines 2008

Inotropic therapy:
Use dobutamine in patients with myocardial dysfunction as supported by elevated cardiac filling pressures and low cardiac output. (1C).

Do not increase cardiac index to predetermined supranormal levels. (1B)

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Conclusion

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THANK YOU
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