53 Vasopressors
53.1 What this covers
- Venous vasoconstriction most important. Less important to increase SVR
- baseline less than 100: 60
- -NE: less splachnic/myocardial ischemia than epi. less digit ischemia than vasopressin. Diminishing returns after 1-2 mcg/kg/min
53.2 Learning objectives
- Venous vasoconstriction most important. Less important to increase SVR
- baseline less than 100: 60
- -NE: less splachnic/myocardial ischemia than epi. less digit ischemia than vasopressin. Diminishing returns after 1-2 mcg/kg/min
- ##When to start Some evidence (earlier normalization of perfusion indices) for earlier than hypotension despite 30cc/kg bolus cyrstalloid: CENSER trial DOI: 10.1164/rccm.201806-1034OC
- ##shock targets -baseline hypertension: 80 -100-140 baseline sbp: 65
- citation doi: 10.1164/rccm.202004-1124ED
- Elderly: 60 (citation and criteria)
53.3 Bottom line / summary
- -NE: less splachnic/myocardial ischemia than epi.
- less digit ischemia than vasopressin.
- Diminishing returns after 1-2 mcg/kg/min
- ##When to start Some evidence (earlier normalization of perfusion indices) for earlier than hypotension despite 30cc/kg bolus cyrstalloid: CENSER trial DOI: 10.1164/rccm.201806-1034OC
- ##shock targets -baseline hypertension: 80 -100-140 baseline sbp: 65
53.4 Approach
- Venous vasoconstriction most important. Less important to increase SVR
- baseline less than 100: 60
- vasopressors
53.5 Red flags / when to escalate
- ##shock targets -baseline hypertension: 80 -100-140 baseline sbp: 65
53.6 Common pitfalls
- TODO: Capture common errors or missed steps.
53.7 References
- https://www.aliem.com/myth-vasopressors-ischemia/
53.8 Source notes
53.8.1 Vasopressors
54 vasopressors
- Venous vasoconstriction = most important. Less important to increase SVR -NE: less splachnic/myocardial ischemia than epi. less digit ischemia than vasopressin. Diminishing returns after 1-2 mcg/kg/min
54.1 When to start
Some evidence (earlier normalization of perfusion indices) for earlier than hypotension despite 30cc/kg bolus cyrstalloid: CENSER trial DOI: 10.1164/rccm.201806-1034OC
54.2 shock targets
-baseline hypertension: 80 -100-140 baseline sbp: 65 - baseline less than 100: 60
citation doi: 10.1164/rccm.202004-1124ED
Elderly: 60 (citation and criteria)
Interestingly - risk of digit necrosis might be an old wives tail - review here: https://www.aliem.com/myth-vasopressors-ischemia/ and that purpura fulminans (sepsis associated activated protein c dysfunction causing microthrombi) with digit ischemia.