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VASOPRESSOR & INOTROPES
IN SHOCK IMBIBE IT & APPLY
IT
VASOPRESSOR & INOTROPES
IN SHOCK IMBIBE IT & APPLY
IT
DR.S.ARUNKUMAR M.D(EM), PG.DIP.(USG),FELL!S"IP IN
IN#ENSI$E %ARE MEDI%INE & E%"%ARDIGRAP"'
EMERGEN%' & %RI#I%AL %ARE P"'SI%IANAS"!INI SPE%IALI#' "SPI#AL,SLAPUR
DR.S.ARUNKUMAR M.D(EM), PG.DIP.(USG),FELL!S"IP IN
IN#ENSI$E %ARE MEDI%INE & E%"%ARDIGRAP"'
EMERGEN%' & %RI#I%AL %ARE P"'SI%IANAS"!INI SPE%IALI#' "SPI#AL,SLAPUR
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Structure of ta*+Structure of ta*+
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 shouldnot
eco!!endations
"rou#leshooting during ad!inistration
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$asoacti-e ae/ts$asoacti-e ae/ts
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So,what are theadrenergic
receptors & how
does it efect on?
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#"ER SPE%IFI% RE%EP#RS#"ER SPE%IFI% RE%EP#RS
DPAMINE RE%EP#RS
Present in the renal,
splanchnic, coronary,
cerebral & vascular beds. Sti!ulation of these
receptors leads to
vasodilation$
Second su#type of
dopa!ine receptors causesvasoconstriction #y inducing
norepinephrine release at
doses %'!cg(kg(!t
$ASPRESSIN RE%EP#RS
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Pri/cip*es f Use f
$asopressors a/0 I/otropes
Pri/cip*es f Use f
$asopressors a/0 I/otropes
Hypotension !ay result fro!) "po-o*eia
Pup fai*ure
Pat1o*oic a*0istri2utio/ of 2*oo0 f*o3
Vasopressors are indicated for) Decrease of 456 "7869 fro 2ase*i/e
SBP or
MAP :;6 " a/0 E-i0e/ce of e/0ora/ 0sfu/ctio/ 0ue to
1poperfusio/
Hypovole!ia !ust #e corrected first
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Epi/ep1ri/eEpi/ep1ri/e
Dose &0i*utio/
Dose ) *+'!cg(!t
,'$-!cg(kg(!t #eta
effects
%'$-!cg(kg(!t+ alpha
effects
.C/S 0+-1!cg(!t
2ntratracheal dose *+*$1ti!es 2V dose
Dilution ) 3!g(*1'!l
Dose of '$*!g(kg CC4
or 44 overdose
%op*icatio/s
"achyarrhyth!ia
/eucocytosis
.ngina & 2ncreases!yocardial o5ygen
de!and
/actic acidosis
Dec renal & splanchnic#lood flow
Hypertension &
pul!onary ede!a
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Nor epi/ep1ri/eNor epi/ep1ri/e
Dose & Di*utio/
Dose ) *+'!cg(!t
.C/S 0+-1!cg(!t
Dilution 3!g(*1'!l Nora0re/a*i/e 2itartrate 8
(/ora0re/a*i/e 2ase
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Dopai/eDopai/e
Dose & Di*utio/
Dose )
'$1+1!cg(kg(!t+
vasodilation 1+'!cg(kg(!t cardiac
sti!ulation7.C/S9
%'!cg(kg(!t+
vasoconstriction
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Do2utai/eDo2utai/e
Dose & Di*utio/
:redo!inantly #eta
effects 7#eta%#eta*9
:otent2notropic(chronotropic
Dose ) *+*' !cg(kg(!in
=a5) 3'!cg(kg(!t
Dilution )*1'!g(*1'!l =a@or use) Systolic
dysfunction
%op*icatio/s
"achyarrhyth!ia &
ventricular ectopy
2ncreases !yocard >*de!and
Aever & headache
Dyspnoea
Can decrease =.: involu!e depleted patients
>ccasional B2 stress
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$asopressi/$asopressi/
Dose & 0i*utio/
Dose :0.01-0.04
units/minute
Dilution :1unit/ml Doses >0.04 units/mt
causes !" & !ardiac
ischemia
pressor e##ects preserved
durin$ hypo%ic and acidotic
conditions
=ay restore C:: after cardiac
arrest without producing
tachycardia
%op*icatio/s
.#d cra!ping8 nausea8
vo!iting
4ronchoconstriction
2ncr liver eny!es
=esentric ische!ia
Venous thro!#osis
Chest pain & =2
Decrease platelets
lactic acidosis
Water into5ication
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I/0icatio/ of -asopresssi/I/0icatio/ of -asopresssi/
Hyper+dyna!ic catechola!ine+resistant
vaso+plegic state
6ot as late rescue therapy in severe
refractory shock
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R"'#"M F DRUGS N
ALP"A & BE#A A%#I$I#'
R"'#"M F DRUGS N
ALP"A & BE#A A%#I$I#'
stro/est
NR
EPINEP"RINE =EPI
NEP"RINE 4DPAMINE4 P"EN'LEP"RINE!EAKES#
EPI
NEP"RINEDPAMINE
NR
EPINEP"RINE4 4
BE#A A%#I$I#'
ALP"A
A%#I$I#'
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#ac1p1*a>is#ac1p1*a>is
esponsiveness to these drugs can decreaseover ti!e due to tachyphyla5is
Doses !ust #e constantly titrated to ad@ust for
this pheno!enon & for changes in patient clinical
condition
How to counteract addition of second line drug
earlier
ioavailability o# subcutaneous heparin or insulin can
be reduced durin$ treatment 'ith vasopressors due
to cutaneous vasoconstriction$
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%*i/ica* Approac1 to s1oc+e0 patie/t%*i/ica* Approac1 to s1oc+e0 patie/t
!1at is s1oc+ ?De#ined by circulatory insu##iciency that creates an imbalance
bet'een the tissue o%y$en supply(delivery) & o%y$en demand
(consumption) 'ith multitude o# or$an dys#unction .
"eo0/aic paraeters Criteria for hypotension drop in sys$ 4:% -'!!hg fro! #aseline or
,E'(F'!!hg or =.: ,F'!!hg
Hypotension does not equate to shock often
Shock Oftenhappens prior to hypotension
Shock !ay happen despite nor!al 4: & conversely 4: !ay #e low
without shock #eing present
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Syste!ic "issue :erfusion
Cardiac >utput7C>9
Heart ate7H9
StrokeVolu!e
7SV9
:reload .fterload Contractility
Syste!ic Vascularesistance 7SV9
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Differe/tiatio/ of s1oc+Differe/tiatio/ of s1oc+
%ar0ioe/ic "po-o*eic Septic
Pu*se pressure G G
Diasto*ic pr G G GGG
E>treities Cool Cool War! initially8 coollater
Nai*e0 2*oo0retur/ Slow Slow apid
@$P G G
Respirator creps III ++ ++
S5 S Ga**op III ++ ++
%1est ra0iorap1 /arge heart8pul!onary ede!a
Di!inished cardiacsie
6or!al8unlesspneu!onia present
I0e/tifie0 site ofi/fectio/
++ ++ III
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%ar0ioe/ic s1oc+%ar0ioe/ic s1oc+
evasculariation i!!ediately is the definitivecare 7TIME IS MUSCLE 9
62V support 7when he!odyna!ically sa#le &
cooperative 9 =echanical ventilation even in nor!al
o5ygenation status with resp distress7to unload
resp$ !uscle workload9 & utiliation of low C>
#y vital organs 2nitial therapy of hypotension
A//
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%ARDIGENI% S"%K ? Approac1%ARDIGENI% S"%K ? Approac1
V 26A.C" W2"H HJ:>";6S2>6
Aluid #olus *1'+1''=/ 7over '+1!inutes9
.6"$W.// 26A.C" W2"H HJ:>";6S2>6 Aluid challenge ''+*1'=/7over '+1!inutes9
Static test
Clinical end points7H 4: vein
co!pressi#ility urine output9
CV::CW:CK:2CC>
D/aic testi/
:assive leg raise testing7pulsepressure variation9
;nd e5piratory occlusion
testing
*cho & + o# ! diameter
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%ar0ioe/ic s1oc+%ar0ioe/ic s1oc+
6>.D;6./26; S" L 1=CBS(="7-$0=/(H92A 4:,0'==HB
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"aper & stop inotropic supports7dopa!ine & do#uta!ine 9 if4: i!proved % #aseline level for that patient(=.: %F1!!hg
"aper noradrenaline once reached 1!cgs(!t dosage
IF BP N# IMPR$ED
Start
EPINEP"RINE( c7t )
Uptitrate to a>iu EPINEP"RINE ? 56cs7t
%$% LINE $asopressors & i/otropic supports 48;1ours71i1 0oses
SI#E ? I@$ (# MNI#R %$P )
AR#ERIAL LINE Epi/ep1ri/e 7 Nora0 4
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Ne3er Sepsis 0efi/itio/86
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Seue/tia* ora/ fai*ure assesse/t(SFA Score)Seue/tia* ora/ fai*ure assesse/t(SFA Score)
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SEP#I% S"%KSEP#I% S"%K
Secure the air3a & 2reat1i/ + septic shock patient
F*ui0 resuscitatio/ + wide #ore 7F B9+ *'+3'!l(kg
crystalloids over -'+F' !inutes with careful vitals !onitoring
RES%UE P#IMIA#IN S#ABILIA#IN DEES%ALA#IN
Rescue 1''!l #olus over 1!inutes(FLUID BOLUS)
ptiiatio/ ''+*''!l over 1+' !inutes(FLUID CHALLENGE)
no longer life threatening8 to opti!ise tissue perfusionSta2i*iatio/ !aintenance fluids for ongoing nor!al fluid loss in
renal8B28 insensi#le loss
Deesca*atio/ stage of negative fluid #alance if warranted #y signs
& sy!pto!s
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FLUID ADMINIS#RA#INFLUID ADMINIS#RA#IN
#ARGE#S IN FLUID #"ERAP'
:ulse volu!e8 o5i!etry 8=.: %F1!!hg & :ulse
pressure variation
"arget CV: N+'c!7non ventilated9( '+*c! H*>7ventilated 9
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$ASPRESSR & IN#RPES ?
SEP#I% S"%K
$ASPRESSR & IN#RPES ?
SEP#I% S"%K
Which Vasopressors to start withOOOOOOOOO
6>+;:26;:H26; ?
D>:.=26; ?
D>42C; ?
o, hich dru$ as second line/rescue therapy
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S"%Ke0 HS"%Ke0 H6>.D;6./26; S" L 1=CBS(="7-$0=/(H9
2A 4:,0'==HB
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t "aper vasopressin L '$1units(hour
2f =.: % F1!!hg
%$% LINE $asopressors & i/otropic supports 48;1ours71i1 0oses
AR#ERIAL LINE $asopressi/ i/0icatio/ 7 Nora0 4"2C>S";>2DS
.DP
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' N# DPAMINE INS#EAD F NRAD' N# DPAMINE INS#EAD F NRAD
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Stu0iesStu0ies
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Stro/ recoe/0atio/sStro/ recoe/0atio/s
Cardiogenic shock + 6orepinephine as first line vasopressor
6orepinephrine stline vasopressor agent for septic shock
Do#uta!ine 2n septic shock for low cardiac output state despite volu!eresuscitation
;pinephrine infusion anaphylactic shock not responding to 2= or 2V #olusepinephrine
;pinephrine is the stline agent in hypotension after C.4B$
6or epinephrine stline vasopressor for undifferentiated shock notresponding to fluid therapy
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%o/0itio/a* recoe/0atio/s%o/0itio/a* recoe/0atio/s
Cardiogenic shock do#uta!ine ad!inistration if inotropedee!ed necessary
outine vasopressor use in hypovole!ic shock notreco!!ended
Vasopressin for he!orrhagic or hypovole!ic shock ifvasopressor dee!ed necessary
Qnown or suspected H>C= or dyna!ic outflow o#structionpts avoid inotropic agents $use vasopressors @udiciously
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%o/0itio/a* recoe/0atio/s%o/0itio/a* recoe/0atio/s
>#structive shock not reponding to specifiedtreat!ent8vasopressor should #e initiated
Vasopressin catechola!ine refractory septic shock
6orad stchoice for distri#utive shock due to hepaticfailure
Short ter! vasopressor infusion ,+*hours throughperipheral line co!plications unlikely
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#rou2*es1ooti/7%1ec+*ists 0uri/
I/otropes & Pressors support
#rou2*es1ooti/7%1ec+*ists 0uri/
I/otropes & Pressors support
2s the patient appropiately !onitored
Had the early use of vasopressors falsely elevated CV: & !asked hypovole!ia
.re the vasopressors !i5ed in correct dose
Vasopressor(inotropes & fluid tu#ing connected in separate line
Check out whether three way port directed properly for flow
624: intervals kept every '!inutes(2nvasive !onitoring .+line positioned( flushedqhour
Cardiac !onitors connected properly for specific patients
:rior filled pressor agents #efore ongoing supports e!pty
Drug na!e(Concentration & colour code la#elling of the various line done
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#a+e 1oe poi/ts#a+e 1oe poi/ts
$asopressi/ ? co/trai/0icate0 i/ %%F pts.(3ater rete/tio/ & se0after*oa0 )
$asopressi/ 2o3e* isc1eia & *actic aci0osis
I/otropes & -asopressor 3o/t 3or+ i/ aci0ic state( p" :.< )
I/otropes receptor 2i/0i/ affi/it a*tere0 2 teperature &co/ce/tratio/
%*assica* i/0icatio/ of so0a 2icar2 ? p":.< to a+e pressors
3or+
Do /ot i-e so0a 2icar2 i/ case of *actic aci0osis
E*e-ate0 *actate ? ar+er of ipaire0 o>e/ 0e*i-er7uti*iatio/
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REFEREN%ESREFEREN%ES
42"2SH P>A .6.;S"H;S2. C.6.D2.6 P>A ;=;B;6CJ =;D2C26;
>Q >A ;=;B;6CJ =;D2C26;
.=;2C.6 :H.=C2S" .SS>C2."2>6 C2"2C./C.; D>Q
:C2;"J >A 26";6S2V; C.;
=;D2C26; 2SCC= P>
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