jacob b. keeperman, md - code 3...
TRANSCRIPT
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Jacob B. Keeperman, MD
Assistant Professor of Anesthesiology and Emergency Medicine Department of Anesthesiology, Division of Critical Care Medicine
Division of Emergency Medicine, Section of EMS Washington University School of Medicine
Saint Louis, Missouri
Medical Director Air Evac Lifeteam
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Disclosures
• I have no financial disclosures to report.
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Vasopressor of Choice for Septic Shock
Targets for Vasopresor Therapy
Clinical Application
What we will cover…
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What pressor does your agency carry?
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Patient Characteristics
Effects on Regional Vascular
Beds
Clinical Trial Results
What is the vasopressor of choice for septic shock?
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BP= CO x SVR
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Pulmonary hypertension? ARDS? HOCM? EF 20%? Cardiac valves? Perioperative MI? Mesenteric ischemia?
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HYPOVOLEMIC
§ Capillary leak (exacerbated by venodilation) § Poor cardiac filling
DISTRIBUTIVE
Macrovascular: § Arterial hypotension § Shunting to “vital” organs § Regional hypoperfusion
Microvascular: § Vasodilation § Precapillary shunting § Impaired microvascular flow § Microvascular thromboses
Mitochondrial dysfunction: § Impaired oxygen utilization § “Cytopathic hypoxia”
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Patient Characteristics
Effects on Regional Vascular
Beds
Clinical Trial Results
What is the vasopressor of choice for septic shock?
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Clinical Trials & Outcome data. Do we have any?
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Effect of norepinephrine on the outcome of septic shock Martin et al, Crit Care Med 2000
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Mortality Rates (%)
Time Period Dopamine NE Odds Ratio P Value
ICU 50.2 45.9 1.19 0.07
Hospital 59.4 56.6 1.12 0.24
28 Days 52.5 48.5 1.17 0.10
6 Month 63.8 62.9 1.06 0.71
12 Month 65.9 63.0 1.15 0.34
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p=0.03
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Vasopressor started, now what?
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Restore perfusion to vital organs
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Increasing MAP?
Bourgoin et al CCM 2005, 33, 780-786
Lactate
DO2
VO2
65 85
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Increasing MAP?
Bourgoin et al CCM 2005, 33, 780-786
UOP
Creatinine
CrCl
65 85
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Increasing MAP from 65 to 85 mmHg
• Does not significantly improve: § systemic oxygen metabolism (DO2/VO2) § skin microcirculatory blood flow § urine output , UF, CrCl, Cr § splanchnic perfusion § lactate clearance
LeDoux et al, Crit Care Med 2000 Bourgoin et al, Crit Care Med 2005
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Clinical Application
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• Fluids or colloids (B) • Dopamine or Norepinephrine first choice (C) • Phenylephrine or Epinephrine second choice (D) • Vasopressin for refractory shock (D) • Dobutamine as inotrope (C)
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• Fluids or colloids (1B) • Fluid challenge (1C) • Dopamine or Norepinephrine first choice (1C) • Epinephrine second choice (2B) • Vasopressin in refractory shock (2C) • Dobutamine as inotrope (1C)
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2012 Guidelines
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2012 Guidelines
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How do I give it?
• Is dopamine safer to give via PIV than norepinephrine?
– There is no evidence to suggest that – What evidence is there?
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How do I give it?
• My patients do not have central lines
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How do I give it?
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• RCT • PIV vs CVC • Analyzed by ITT • Results – less major complications with
CVC rather than PIV (0.64 vs 1.04, p<0.02)
• The majority of complications in the PIV group were the inability to insert a PIV
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What we want to know:
• Were there extravasation injuries in the PIV group? – Included very high doses
• Up to 2 mg/hr (33.3 mcg/min) of norepinephrine or epinephrine
• Up to 10 mg/kg/min of dopamine or dobutamine
– 19 patients in the PIV group had extravasation • None of them required anything more than
observation and conservative treatment*
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What does the study mean?
• You can give pressors via PIV
• There are risks with all pressors (including dopamine)
_________________________________
• We need to investigate the use of pressors via IO
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What if there is extravasation? • If patient is relying on the pressor,
infuse via new access (IV, IO) • Aspirate from the IV that infiltrated • Give phentolamine (Regitine)
– Comes 5 mg / 1 mL – Place in 9 mL NS – Dose: 0.1 – 0.2 mg/kg (up to 10 mg) – Inject a few mLs via the infiltrated catheter
and the remaining SQ around the borders of the extravasation
• Consult plastic surgery
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Push-Dose-Pressors
• Term coined by Scott Weingart, MD
• Used by OB anesthesia for a long time
• Quick bolus of vasopressor during duress
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Push-Dose-Pressors
• Idea – Hypotension should be corrected quickly – Push drugs result in hypotension, so push
drugs should be used to correct hypotension
– Typically use phenylephrine or epinephrine – You might be able to use norepinephrine
(we need a study)
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Push-Dose-Pressors EPINEPHRINE • Receptors: Alpha and beta • Mixing:
– 1 mL of epinephrine from cardiac epinephrine ampule (100 mcg/mL)
– 9 mL of normal saline in 10 mL syringe – 10 mL of epinephrine 10 mcg/mL (same
concentration as lidocaine with epi) • Dose: 0.5 - 2 mL q 2-5 minutes
*** Do NOT give cardiac arrest dose (1 mg) to patients with a pulse
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Push-Dose-Pressors PHENYLEPHRINE • Receptors: Pure alpha
– No intrinsic inotropy – May cause increased coronary perfusion
which may increase CO – I only use it in tachycardic patients
• Mixing – 1 ml phenylephrine from vial (10 mg/mL) – Inject into 100 mL bag normal saline – Phenylephrine 100 mcg/mL
• Dose: 0.5 - 2 mL q 2 - 5 minutes
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Push-Dose-Pressors
• Pit-falls – Errors in mixing
• Solution – Pre-mixed syringes
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Conclusions
• Fill the tank first • The first line pressor choice should be
norepinephrine (Levophed) • Pressors can be given via peripheral IV • Need to evaluate pressors via IO • Push-dose-pressors are coming to the
out-of-hospital setting
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References • EMCrit • Berben JY, Bryant MF, Howard JM. Etiology and prevention of sloughs produced by L-norepinephrine (levophed). Annals of surgery, 1957. no. 6.
http://www.ncbi.nlm.nih.gov/pubmed/13488384. • Bunker N, Higgins D. Peripheral administration of vasopressin for catecholamine-resistant hypotension complicated by skin necrosis. Critical care medicine,
2006. no. 3. http://www.ncbi.nlm.nih.gov/pubmed/16505698. • Chen JL, O’Shea M. Extravasation injury associated with low-dose dopamine. The Annals of pharmacotherapy, 1998. no. 5.
http://www.ncbi.nlm.nih.gov/pubmed/9606475. • Kahn JM, Kress JP, Hall JB. Skin necrosis after extravasation of low-dose vasopressin administered for septic shock. Critical care medicine, 2002. no. 8.
http://www.ncbi.nlm.nih.gov/pubmed/12163813. • Khan JM, Mansoor S, Holmes JD. Reducing the morbidity from extravasation injuries. Annals of plastic surgery, 2002 no. 6.
http://www.ncbi.nlm.nih.gov/pubmed/12055433. • Mcginn JT, Schluger J. Skin sloughs associated with levophed; pathogenesis, prevention and treatment. American journal of surgery, 1956 no. 4.
http://www.ncbi.nlm.nih.gov/pubmed/13362728. • Pelner L, Waldman S, Rhoades MG. The problem of levarterenol (levophed) extravasation an experimental study. The American journal of the medical sciences,
1958no. 6. http://www.ncbi.nlm.nih.gov/pubmed/13606129. • Raszka WV, Kueser TK, Smith FR, et al. The use of hyaluronidase in the treatment of intravenous extravasation injuries. Journal of perinatology : official journal of
the California Perinatal Association, 1999 no. 2. http://www.ncbi.nlm.nih.gov/pubmed/2358898. • Ricard JD, Salomon L, Boyer A, et al. Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Critical care
medicine, 2013 no. 9. doi:10.1097/CCM.0b013e31828a42c5. http://www.ncbi.nlm.nih.gov/pubmed/23782969. • Zucker G. Use of phentolamine to prevent necrosis due to levarterenol. Journal of the American Medical Association, 1957 no. 16 ( 20).
http://www.ncbi.nlm.nih.gov/pubmed/13415911. • Zucker G, Eisinger RP, Floch MH, et al. Treatment of shock and prevention of ischemic necrosis with levarterenol-phentolamine mixtures. Circulation. 1960.
http://www.ncbi.nlm.nih.gov/pubmed/13788877. • Ngan Kee WD, Khaw KS, Lau TK, et al. Randomised double-blinded comparison of phenylephrine vs ephedrine for maintaining blood pressure during spinal
anaesthesia for non-elective Caesarean section. Anaesthesia. 2008 Dec;63(12):1319-26. doi: 10.1111/j.1365-2044.2008.05635.x. • Mullner M, Urbanek B, Havel C, et al. Vasopressors for shock. Cochrane Database Syst Rev 2004;:CD003709. • Practice parameters for hemodynamic support of sepsis in adult patients in sepsis. Task Force of the American College of Critical Care Medicine, Society of
Critical Care Medicine. Crit Care Med 1999;27:639. • Moran JL, O’Fathartaigh MS, Peisach AR, et al. Epinephrine as an inotropic agent in septic shock: a dose-profile analysis. Crit Care Med 1993;21:70. • Martin C, Papazian L, Perrin G, et al. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock? Chest 1993;103:1826.
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References • Gregory JS, Bonfiglio MF, Dasta JF, et al. Experience with phenylephrine as a component of the pharmacologic support of septic shock Crit Care Med
1991;19:1395. • Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care
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Code3 Conference Planning Committee
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