Basic Life Support

VASOPRESSOR & INOTROPES

IN SHOCK IMBIBE IT & APPLY
IT

DR.S.ARUNKUMAR M.D(EM), PG.DIP.(USG),

FELLOWSHIP IN
INTENSIVE CARE MEDICINE & ECHOCARDIOGRAPHY
EMERGENCY & CRITICAL CARE PHYSICIAN
ASHWINI SPECIALITY HOSPITAL,SOLAPUR

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Structure of my talk
What is in your hand ?
Various receptors & its effect
Drugs Heroic & villain character
Clinical approach to cardiogenic & septic shock
Studies quoting what you should use & what you should
not
Recommendations
Troubleshooting during administration

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Vaso-active agents

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So,what are the

adrenergic
receptors & how
does it effect on?

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OTHER SPECIFIC RECEPTORS

DOPAMINE RECEPTORS
Present in the renal,
splanchnic, coronary,
cerebral & vascular beds.
Stimulation of these
receptors leads to
vasodilation.
Second subtype of
dopamine receptors causes
vasoconstriction by inducing
norepinephrine release at
doses >10mcg/kg/mt

VASOPRESSIN RECEPTORS

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Principles Of Use Of
Vasopressors and Inotropes

Hypotension may result from:

Hypovolemia
Pump failure
Pathologic maldistribution of blood flow

Vasopressors are indicated for:

Decrease of >30 mmHg/20% from baseline
SBP or
MAP <60 mmHg and
Evidence of end-organ dysfunction due to
hypoperfusion

Hypovolemia must be corrected first

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Epinephrine
Dose &dilution
Dose : 2-10mcg/mt
<0.3mcg/kg/mt beta
effects
>0.3mcg/kg/mt- alpha
effects
ACLS 7-35mcg/mt
Intratracheal dose 2-2.5
times IV dose
Dilution : 4mg/250ml
Dose of 0.2mg/kg CCB
or BB overdose

Complications
Tachyarrhythmia
Leucocytosis
Angina & Increases
myocardial oxygen
demand
Lactic acidosis
Dec renal & splanchnic
blood flow
Hypertension &
pulmonary edema

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Nor epinephrine
Dose & Dilution

Dose : 2-10mcg/mt
ACLS 7-35mcg/mt
Dilution 4mg/250ml
Noradrenaline bitartrate 2mg
(noradrenaline base 1mg)
Alpha effect > beta effect
Ideal solution D5W or D5NS
Do not administer along with
soda bicarb soln.

Complications
Ischemia of end
organs(kidneys, gut, liver,
extremities)
Pulmonary vasoconstriction,
Arrhythmias, and
skin necrosis with
extravasation
Spares the coronary circulation

Extravasation treatment 5-10mg in 10-15ml saline

- Phentolamine

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Dopamine
Dose & Dilution
Dose :
0.5-5mcg/kg/mtvasodilation
5-10mcg/kg/mt cardiac
stimulation(ACLS)
>10mcg/kg/mtvasoconstriction
Upto 20mcg/kg/mt
desired resp.
Max: 50mcg/kg/mt
Dilution :400mg/250ml

Complications
Tachyarrhythmia
Increases myocardial O2
consumption
response can diminish when
NE stores depleted,
sinus/atrial/ventricular
tachycardia or arrhythmias
occur
Prolonged clearance in
combined hepatic & renal
dysfunction
Worsen MI If BP doesnt
improve coronary flow earlier

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Dobutamine
Dose & Dilution
Predominantly beta
effects (beta1>beta2)
Potent
Inotropic/chronotropic
Dose : 2-20 mcg/kg/min
Max: 40mcg/kg/mt
Dilution :250mg/250ml
Major use: Systolic
dysfunction

Complications
Tachyarrhythmia &
ventricular ectopy
Increases myocard O2
demand
Fever & headache
Dyspnoea
Can decrease MAP in
volume depleted patients
Occasional GI stress

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Vasopressin
Dose & dilution

Complications

Dose :0.01-0.04
units/minute
Dilution :1unit/ml
Doses >0.04 units/mt
causes CO & Cardiac
ischemia

Abd cramping, nausea,

vomiting
Bronchoconstriction
Incr liver enzymes
Mesentric ischemia
Venous thrombosis
Chest pain & MI
Decrease platelets
lactic acidosis

pressor effects preserved

during hypoxic and acidotic
conditions
May restore CPP after cardiac
arrest without producing
tachycardia

Water intoxication

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Indication of vasopresssin
Hyper-dynamic ; catecholamine-resistant ;
vaso-plegic state
Not as late rescue therapy in severe
refractory shock
Used in less severe shock
Vasopressin deficient state sepsis
Diabetes insipidus;GI hemorrhage;
oesophageal varices;
Postoperative abdominal distension

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RHYTHM OF DRUGS ON
ALPHA & BETA ACTIVITY

strongest

ALPHA
ACTIVITY
NOR
EPI
EPINEPHRINE NEPHRINE

>

DOPAMINE

>

PHENYL
EPHRINE

BETA ACTIVITY
EPI
NEPHRINE

>

DOPAMINE

>

NOR
EPINEPHRINE

WEAKEST

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Tachyphylaxis
Responsiveness to these drugs can decrease
over time due to tachyphylaxis
Doses must be constantly titrated to adjust for
this phenomenon & for changes in patient clinical
condition
How to counteract addition of second line drug
earlier

Bioavailability of subcutaneous heparin or insulin can

be reduced during treatment with vasopressors due
to cutaneous vasoconstriction.

Clinical Approach to shocked patient

Basic Life Support

What is shock
Defined by circulatory insufficiency that creates an imbalance
between the tissue oxygen supply(delivery) & oxygen demand
(consumption) with multitude of organ dysfunction .
Hemodynamic parameters
Criteria for hypotension drop in sys. BP> 30mmhg from baseline or
<90/60mmhg or MAP <60mmhg
Hypotension does not equate to shock often
Shock Often happens prior to hypotension
Shock may happen despite normal BP & conversely BP may be low
without shock being present

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Systemic Tissue Perfusion

Systemic Vascular
Resistance (SVR)

Cardiac Output
(CO)

Heart Rate
(HR)

Preload

Stroke
Volume
(SV)

Afterload

Contractility

Cardiogenic

Hypovolemic

Septic

Basic Life Support

Differentiation of shock

Pulse pressure

Diastolic pr

Extremities

Cool

Cool

Warm initially, cool

later

Nailed blood
return

Slow

Slow

Rapid

JVP

Respiratory creps

+++

--

--

S3 S4 Gallop

+++

--

--

Chest radiograph

Large heart,
pulmonary edema

Diminished cardiac
size

Normal,unless
pneumonia present

Identified site of
infection

--

--

+++

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Cardiogenic shock
Revascularization immediately is the definitive
care (TIME IS MUSCLE )
NIV support (when hemodynamically sable &
cooperative )
Mechanical ventilation even in normal
oxygenation status with resp distress(to unload
resp. muscle workload) & utilization of low CO
by vital organs
Initial therapy of hypotension
FLUID CHALLENGE / BOLUS

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CARDIOGENIC SHOCK Approach

RV INFARCT WITH HYPOTENSION
Fluid bolus 250-500ML (over 10-15minutes)
ANT.WALL INFARCT WITH HYPOTENSION
Fluid challenge 100-250ML(over 10-15minutes)
Static test
Clinical end points
(HR; BP ;vein
compressibility; urine output)
CVP;PCWP;CXR;PICCO;

Dynamic testing
Passive leg raise testing(pulse
pressure variation)
End expiratory occlusion
testing

Echo & USG of IVC diameter

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Cardiogenic shock
NORADRENALINE SUPPORT @ 5MCGS/MT(3.7ML/HR)
IF BP<70MMHG
Uptitrate 1ml/hour every 15minutes
Upper limit for Noradrenaline 15-20mcgs/mt

IF SBP > 100mmhg

IF SBP < 90mmhg

Dobutamine 2.5mcg/kg/mt
Uptitrate 1ml/hr Q15mts

Dopamine -5mcg/kg/mt
Uptitrate 1ml/hr Q15mts

B.P>110/80 ,
Taper norad <10mcgs/mt

B.P>110/80,
Taper norad <10mcgs/mt

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Taper & stop inotropic supports(dopamine & dobutamine ) if

BP improved > baseline level for that patient/MAP >65mmhg
Taper noradrenaline once reached 5mcgs/mt dosage
IF BP NOT IMPROVED
Start
EPINEPHRINE( 7mcg/mt )

Uptitrate to maximum EPINEPHRINE 30mcgs/mt

CVC LINE - Vasopressors & inotropic supports >2-6hours/high doses
SITE IJV (TO MONITOR CVP )
ARTERIAL LINE - Epinephrine / Norad - >15mcg/mt
SITE FEMORAL (MORE ACCURATE & BETTER APPROX AORTIC PR)

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Newer Sepsis definition-2016

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Sequential organ failure assessment(SOFA Score)

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SEPTIC SHOCK
Secure the airway & breathing - septic shock patient

Fluid resuscitation - wide bore (16 G)- 20-40ml/kg

crystalloids over 30-60 minutes with careful vitals monitoring

RESCUE ----- OPTIMIZATION ---- STABILIZATION ---- DE-ESCALATION

Rescue
500ml bolus over 15minutes(FLUID BOLUS)
Optimization 100-200ml over 5-10 minutes(FLUID CHALLENGE)
no longer life threatening, to optimise tissue perfusion
Stabilization maintenance fluids for ongoing normal fluid loss in
renal,GI, insensible loss
Deescalation stage of negative fluid balance if warranted by signs
& symptoms

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FLUID ADMINISTRATION
TARGETS IN FLUID THERAPY

Pulse volume, oximetry ,MAP >65mmhg & Pulse

pressure variation
Target CVP 8-10cm(non ventilated)/
10-12cm H2O(ventilated )
Urine output > 0.5ml/kg/hr

IV albumin when excess crystalloids are needed

No role for colloids (hydroxy ethyl starch risk of
nephrotoxicity& dec. oxygen carrying capacity)

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VASOPRESSOR & INOTROPES

SEPTIC SHOCK
Which Vasopressors to start with!!!!!!!!!

NOR-EPINEPHRINE ?
DOPAMINE ?
DOBUTAMINE ?
EPINEPHRINE ?
VASOPRESSIN AS FIRST CHOICE ?

So, Which drug as second line/rescue therapy?

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SHOCKed ?
NORADRENALINE SUPPORT @ 5MCGS/MT(3.7ML/HR)
IF BP<70MMHG
Uptitrate 1ml/hour every 15minutes
Upper limit for Noradrenaline 15-20mcgs/mt
IF SBP > 100mmhg
<120mmhg & low cardiac
output
Dobutamine 2.5mcg/kg/mt
Uptitrate 1ml/hr Q30mts
Max :10-15mcg/mt
B.P>110/80 ,continue dobut @ low dose
& Taper norad upto 5mcgs/mt

IF SBP < 90mmhg

Vasopressin 0.01
0.04units/mt
(if norad >15mcg/mt)
required
Upper limit
0.06units/mt

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Taper vasopressin @ 0.5units/hour

If MAP > 65mmhg

Coadministration of EARLY CORTICOSTEROIDS

ADJUVANT ROLE & BENEFICIAL
HYDROCORT 300MG/DAY IN DIVIDED DOSE OR
10MG/HOUR INFUSION

STEROIDS CONTINUED UNTIL VASOPRESSOR SUPPORT

STOPPED

CVC LINE - Vasopressors & inotropic supports >2-6hours/high doses

ARTERIAL LINE - Vasopressin indication / Norad - >15mcg/mt

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Y NOT DOPAMINE INSTEAD OF NORAD

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Studies

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Strong recommendations
Basic Life Support

Cardiogenic shock - Norepinephine as first line vasopressor

Norepinephrine 1st line vasopressor agent for septic shock
Dobutamine In septic shock for low cardiac output state despite volume
resuscitation
Epinephrine infusion anaphylactic shock not responding to IM or IV bolus
epinephrine
Epinephrine is the 1st line agent in hypotension after CABG.
Nor epinephrine 1st line vasopressor for undifferentiated shock not
responding to fluid therapy

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Conditional recommendations
Cardiogenic shock dobutamine administration if inotrope
deemed necessary
Routine vasopressor use in hypovolemic shock not
recommended
Vasopressin for hemorrhagic or hypovolemic shock if
vasopressor deemed necessary
Known or suspected HOCM or dynamic outflow obstruction
pts avoid inotropic agents .use vasopressors judiciously

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Conditional recommendations
Obstructive shock not reponding to specified
treatment,vasopressor should be initiated
Vasopressin catecholamine refractory septic shock
Norad 1st choice for distributive shock due to hepatic
failure
Short term vasopressor infusion <1-2hours through
peripheral line complications unlikely
Undifferentiated shock ,2nd vasopressor to be started if
MAP <70mmhg

Troubleshooting/Checklists during
Inotropes & Pressors support
Basic Life Support

Is the patient appropiately monitored

Had the early use of vasopressors falsely elevated CVP & masked hypovolemia
Are the vasopressors mixed in correct dose
Vasopressor/inotropes & fluid tubing connected in separate line
Check out whether three way port directed properly for flow
NIBP intervals kept every 10minutes/Invasive monitoring A-line positioned/ flushed
q1hour
Cardiac monitors connected properly for specific patients
Prior filled pressor agents before ongoing supports empty
Drug name/Concentration & colour code labelling of the various line done

Take home points

Basic Life Support

Vasopressin contraindicated in CCF pts.(water retention & sed

afterload )
Vasopressin- bowel ischemia & lactic acidosis
Inotropes & vasopressor wont work in acidic state( pH <7.1 )
Inotropes receptor binding affinity altered by temperature &
concentration
Classical indication of soda bicarb pH<7.1 to make pressors
work
Do not give soda bicarb in case of lactic acidosis
Elevated lactate marker of impaired oxygen delivery/utilization

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REFERENCES
BRITISH JOURNAL OF ANAESTHESIA
CANADIAN JOURNAL OF EMERGENCY MEDICINE
UPTODATE
TINTINALLI TEXTBOOK OF EMERGENCY MEDICINE
AMERICAN PHARMCIST ASSOCIATION CRITICAL
CARE DRUG BOOK
PUBMED
EUROPEAN SOCIETY OF INTENSIVE CARE
MEDICINE
ISCCM JOURNAL ARTICLE

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