EM · Vasoactive drugs in resuscitation
Vasoactive drugs in resuscitation
Also known as Vasopressors and inotropes · Inotropes in shock · Catecholamine therapy · Pressor use in the shocked patient
Vasoactive drugs in resuscitation — the receptor pharmacology that decides which agent to reach for (noradrenaline alpha-greater-than-beta is the first-line vasopressor of septic and most distributive shock; adrenaline the alpha-plus-beta agent of anaphylaxis and cardiac arrest; vasopressin the V1-receptor catecholamine-sparing adjunct of septic shock; dopamine avoided because of SOAP II; dobutamine the beta-1 inotrope of cardiogenic shock; milrinone the selective PDE-3 inodilator useful for the right heart and the pulmonary vasculature), the selection of the agent by the shock type and the haemodynamic phenotype, the peripheral-versus-central administration question, and the full weight-based dosing reference. The landmark trials are SOAP II (noradrenaline over dopamine), VASST and VANISH (vasopressin), SEPSISPAM (the MAP target), APROCCHSS (hydrocortisone as the catecholamine-sparing adjunct), CLOVERS (the early vasopressor versus the early fluid) and the Surviving Sepsis Campaign 2021 framework. ACEM-primary, globally tagged.
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8 MCQs with explanations
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Meet the patient
A 62-year-old with community-acquired pneumonia is brought in cold, clammy and confused after 30 mL/kg of crystalloid on the ward. MAP 52, lactate 4.6, heart rate 124, a peripheral cannula still in his antecubital fossa. The registrar wants to site a central line before giving anything.[6]
The question that decides his next hour is the question that decides every shocked patient: is the problem the pressure (vasoplegia), the pump (cardiogenic), or the pipe (obstruction)? In this man it is the pressure — and the next move is noradrenaline through the cannula already in his arm, not a delay for the line.[6]
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- [1]De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock (SOAP II). New England Journal of Medicine, 2010.PMID 20200382
- [2]Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepinephrine infusion in patients with septic shock (VASST). New England Journal of Medicine, 2008.PMID 18305265
- [3]Gordon AC, Mason AJ, Thirunavukkarasu N, et al. Effect of Early Vasopressin vs Norepinephrine on Kidney Failure in Patients With Septic Shock (VANISH). JAMA, 2016.PMID 27483065
- [4]Asfar P, Meziani F, Hamel JF, et al. High versus low blood-pressure target in patients with septic shock (SEPSISPAM). New England Journal of Medicine, 2014.PMID 24635770
- [5]Annane D, Renault A, Brun-Buisson C, et al. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock (APROCCHSS). New England Journal of Medicine, 2018.PMID 29490185
- [6]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Medicine, 2021.PMID 34599691
- [7]National Heart, Lung, and Blood Institute PETAL Clinical Trials Network; Shapiro NI, Douglas IS, et al. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension (CLOVERS). New England Journal of Medicine, 2023.PMID 36688507