Ionotropes and vasopressor use in the ED
-
Upload
scgh-ed-cme -
Category
Documents
-
view
1.099 -
download
1
description
Transcript of Ionotropes and vasopressor use in the ED
Inotropes and Vasopressors for the ED
20th February 2014
ED scenarios Indication for inotropes Choice of agent
Overview
57 year old lady Brought in by husband as she has abdominal
pain and seems slightly confused
Obs T39, P128, BP 75/40, RR22, sats 98% OA, BSL 4.8
ECG Sinus tachycardia
Case 1
How would you manage this patient?
Shock is the failure to adequately oxygenate tissues to meet metabolic demand, resulting in end organ failure.
Adjustable factors affecting tissue oxygenation [Hb] PaO2 Cardiac output Systemic vascular resistance
Shock
Which drug for this patient?
Receptors
Action Dose μg/kg/min
Side effects
Noradrenaline
α1(some β1 at low doses)
Vasoconstriction and increased SVR
0.03-0.2 Increased afterload causing reduced SV and increased myocardial oxygen demand
Noradrenaline
Dopamine
Receptors Action Dose μg/kg/min
Side effects
Dopamine Vasodilation of capillary beds, reduced SVR
1-3
β1 Increased SV and CO
3-10 Tachyarrythmia
α1 Vasoconstriction, increased MAP
>10
Meta-analysis by De Backer et al 2012 6 randomised trials, 1,408 patients Primary end point – mortality at 28 days 732 received dopamine, 676 to
noradrenaline Median exposure 2 days Conclusion: Dopamine associated with
greater mortality than noradrenaline and a greater number of arrhythmic events.
Increased risk of death RR=1.12 (CI 1.01-1.20)
Dopamine versus noradrenaline for the treatment of septic shock
Access is difficult –just one pink line USS guided access is also attempted
Back to the patient..
EMCRIT 107 French RCT where ICU patients were
randomised to peripheral (n=128) or central access (n=135)
Most complication in the peripheral group was extravasation injury
Most common in CVC group was infectious Is extravasation an acceptable risk?
Peripheral use of inotropes
Case 2 32 year old male, football injury, presents with right shoulder pain
Obs Afebrile, P 80, BP 130/80, RR 20, Sats 100% OA, BSL 5.0
100mcg of fentanyl with the ambulance Anaesthetic assessment, fasted, no regular
medications, ECG sinus He is sedated and the shoulder is relocated.
Management
Shoulder relocated Obs P 60, BP 65/40, RR 20, Sats 100% OA,
BSL 5.0
Case 2 continued
Receptors
Action Dose Side effects
Metaraminol
Indirect release of NA
Vasoconstriction
0.5mg bolus
Hypertension tachycardia
Adrenaline Low dose β1>β2
Increased HR, SV and CO
<0.02 HTN, tachyarrythmia, Hyperglycaemia, hypokalaemia
High dose α1
>0.02
Indication is transient hypotension During sedation Post intubation Whilst waiting for inotropes to work or CVC
lines to be sited Transfers
Push dose pressors
84 year old lady
PC: Dizzyness and palpitations
HPC: Felt light headed on standing, developed palpitations and central burning chest pain associated with SOB and a feeling that she might collapse. Pain lasted 10 mins.
Obs Afebrile, P40, BP 209/100, RR22, 96% OA, BSL 6.3
Case 3
ECG
Called to see the patient who has had a short lived presyncopal episode
Obs Afeb HR 20, BP 180/90, RR 20, 96%OA ECG
Meanwhile..
ECG
What is your management?
Reversible causes – ischaemia, drugs
Discussed with Cardiology consultant: admit to CCU for telemetry and isoprenaline
Complete heart block
Receptors
Action Dose Side effects
Isoprenaline
B1>B2 Positive inotrope and chronotrope,
Infusion 0.5-5 mcg/min
Increases myocardial oxygen demands
Isoprenaline
What kind of drugs can we use? Iontropes
Adrenaline Dobutamine
Vasopressors Noradrenaline Metarminol
Chronotropes Isoprenaline
Summary
Actions of these drugs depend on the receptors they activate and the concentration of the drug
Most commonly used for management of shock
Determining the type of shock is important in choice of drug
Range of application in the ED Bridging therapy to allow treatments for shock to
take effect To counteract transient effects of other drugs
Summary
De Backer et al. (2012) Dopamine versus norepinephrine in the treatment of septic shock: A meta-analysis. Crit Care Med. Vol 40. p 725
Senz A (2009) Review article: inotrope and vasopressor use the emergency department. Emerg Med Australas. 2009 Oct;21(5):342-51
Benham-Hermetz (2012) Cardiovascular failure, inotropes and vasopressors British Journal of Hospital Medicine May,Vol73,No5
EMCRIT Podcast 107 http://emcrit.org/podcasts/peripheral-vasopressors-extravasation/
RAGE Podcast 1 http://ragepodcast.com/rage-session-one/ Push dose pressors April 2013 http
://www.emrap.org/episode/2013
References