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