Vasopressors and Inotropes in Canadian Emergency Departments
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Transcript Vasopressors and Inotropes in Canadian Emergency Departments
Vasopressors and
Inotropes in Canadian
Emergency Departments
Dennis Djogovic MD, FRCPC
Financial Disclosures
None to declare
ER docs treat shock
There are no evidence based guidelines to assist in
which pressor/trope to use in shock
VICE has created a document to address that
CAEP standards committee
CJEM
VICE squad
Shavaun MacDonald
Rob Green
Andrea Wensel
Osama Loubani
James Lee
Patrick Archambault
Janeva Kircher
Simon Bordeleau
Katherine Smith
Adam Szulewski
Jon Davidow
Sara Gray
Dennis Djogovic
Jean Marc Benoit
David Messenger
Dan Howes
What is Shock?
What are the types of shock?
Cardiogenic
Obstructive
Distributive
Hypovolemic
What are vasopressors?
Systemic vasoconstriction
Pulmonary vasoconstriction
Increase Mean Arterial Pressure (MAP)
What are inotropes?
Agents that increase cardiac output
Increase inotropy
Increase chronotropy
Decrease afterload
Inotropes
Vasopressors
Intra aortic Balloon Pump
Phenylephrine
Dobutamine
Ephedrine
Isoproteronol
Norepinephrine
Epinephrine
Dopamine
Milrinone
Nitroprusside
Digoxin
Different shock types need
different managment
Guidelines based on different shock types
Research methodology
(only one slide!)
AGREE II
PICO questions
Section authors/literature review
GRADE
Quality of evidence
Strength of recommendation
Delphi consensus process
88 530 articles identified
1040 articles in focused article list
113 articles used for grading purposes
7 clinical questions
18 recommendations
5 strong
13 conditional
Quality of Evidence
A= High Level of evidence
Good RCT
B= Moderate
Poor RCT, well done observational series
C= low
Poor observational series
D= very low
Case series, expert opinion
Strength of Recommendation
Balance desirable and undesirable effects
Quality of evidence
Values and preferences
costs
Strength of Recommendation
Strong
Conditional
70% of votes needed for “Strong” recommendation
Question 1: For ED patients in shock,
what are the side effects of
vasopressors and inotropes?
Dopamine increases the risk of tachyarrhythmia
compared to norepinephrine. (Grade A).
Dopamine use in septic shock increases mortality
compared to norepinephrine (Grade B).
Vasopressin as a first line vasopressor may be
associated with cellular ischemia and skin necrosis,
particularly when combined with sustained moderate
to high dose infusions of norepinephrine. (Grade C).
Epinephrine increases metabolic abnormalities
compared to norepinephrine. (Grade A).
Epinephrine increases metabolic abnormalities
compared to norepinephrine-dobutamine in
cardiogenic shock without acute cardiac ischemia.
(Grade B).
Question 2: Which vasopressors and
inotropes should be used in the treatment
of ED patients with cardiogenic shock?
Recommendation: Cardiogenic shock patients in the
ED should receive norepinephrine as the first-line
vasopressor. (Strong)
Question 2: Which vasopressors and
inotropes should be used in the treatment
of ED patients with cardiogenic shock?
Recommendation: Cardiogenic shock patients in the
ED should receive dobutamine if an inotrope is
deemed necessary. (Conditional)
Question 3: Which vasopressors and
inotropes should be used in the treatment
of ED patients with hypovolemic shock?
Recommendation: Routine vasopressor use in
hypovolemic shock is not recommended.
(Conditional)
Recommendation: Vasopressin may be indicated in
hemorrhagic or hypovolemic shock if a vasopressor is
deemed necessary. (Conditional)
Question 4: Which vasopressors and
inotropes should be used in ED
patients with obstructive shock?
Recommendation: In obstructive shock not
responding to indicated treatment, a systemically
active vasopressor should be instituted. (Conditional)
Question 4: Which vasopressors and
inotropes should be used in ED
patients with obstructive shock?
Recommendation: For patients with known or
suspected hypertrophic obstructive cardiomyopathy
(HOCM) or dynamic outflow obstruction, inotropic
agents should be avoided. Judicious use of
vasoconstrictive agents can be considered.
(Conditional)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
Recommendations: Norepinephrine is the first line
vasopressor for use in septic shock. (Strong)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
Recommendation: Vasopressin should be considered
in catecholamine refractory septic shock.
(Conditional)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
Recommendation: Dobutamine should be used for
septic shock with low cardiac output despite
adequate volume resuscitation. (Strong)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
Recommendation: Vasopressor choice in neurogenic
shock is not clear. The agent should be determined
by patient characteristics and response to treatment.
(Conditional)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
Recommendation: Norepinephrine is the first line agent
for the management of distributive shock due to
hepatic failure. (Conditional)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
Recommendation: Epinephrine infusion is the
preferred agent for anaphylactic shock that does not
respond to intramuscular or intravenous bolus
epinephrine. (Strong)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
Recommendation: Vasopressor choice in distributive
shock secondary to adrenal insufficiency not
responding to steroid replacement is not clear.
Patient response to chosen agents should guide
therapy. (Conditional)
Question 6: Which vasopressors and
inotropes should be used in ED
patients with undifferentiated shock?
Recommendation: In undifferentiated shock not
responding to fluid resuscitation, norepinephrine
should be the first-line vasopressor. (Strong)
Question 6: Which vasopressors and
inotropes should be used in ED
patients with undifferentiated shock?
Recommendation: In undifferentiated shock, a second
vasopressor should be added if a goal MAP>70mmHg is
not being achieved. (Conditional)
Question 7: How should vasopressors
and inotropes be administered to ED
patients?
Recommendation: Short term vasopressor infusions
(<1-2 hours) or boluses via properly positioned and
functioning peripheral intravenous catheters are
unlikely to cause local complications. (Conditional)
Question 7: How should vasopressors
and inotropes be administered to ED
patients?
Recommendation: Vasopressor infusions for prolonged
periods (>2-6 hours) should preferentially be
administered via central venous catheters.
(Conditional)
Question 7: How should vasopressors
and inotropes be administered to ED
patients?
Recommendation: Inotropes can be given via
peripheral catheter (short term) or central venous
catheters (prolonged period) with a similarly low
incidence of local complications. (Conditional)
Question 7: How should vasopressors
and inotropes be administered to ED
patients?
Recommendation: The administration of vasopressors
via intra-osseous lines is safe in adults. (Conditional)
Question 7: How should vasopressors
and inotropes be administered to ED
patients?
In summary
Identify the type of shock
To determine the type of treatment
Norepi > dopamine
Cross your fingers!