Inservice In The Break Room: Pressors

What do you do when presented with a hypotensive patient resistant to IV fluids? Maybe throw some steroids at ’em but more likely you start dopamine. This is our go-to drug of choice as a pressor. However recent literature has shown it to be falling out of favor (ie, septic shock). So what should we use? Norepinephrine and phenylephrine.

Why do we use dopamine? Speaking from a doctor’s perspective, it’s familiarity. We know how to use it. However it may have more arryhthmogenic effects (in cardiogenic shock). There are drugs which are just as effective and probably more so… shouldn’t we get learn to use something new… or in this case, something old…?

* NOREPINEPHRINE 1 MICROgrams/min IV and titrate as high as 30 MICROgrams/min

Yes, some of you may remember this little fellow by his other name, “leave-em-dead,” but that’s a bit of a misnomer. I believe that name arose from the fact that if you were reaching for this drug, the patient wasn’t doing so well.

Goals of early goal directed therapy in sepsis requires quick restoration of perfusion to tissues. When fluids don’t cut it, vasopressors are needed to increase cardiac output and oxygenation. Norepi may be a more potent vasopressor than dopamine.

Hopefully this should go in through a central line, but what if you don’t got one? Well anesthesiologists commonly push pressors through a peripheral IV. GASP! Yes, a peripheral. Phenylephrine works well for this. This is called “push dose pressors.”

* PHENYLEPHRINE 50 MICROgrams IV push (with flush)

You should hopefully see an improvement in blood pressure in a minute or two, and it only lasts about 5 minutes.

So next time we have a code together and I ask for “push dose phenylephrine” don’t look at me funny. Instead

  1. grab a vial of phenylephrine (10 mg in 1 mL) and
  2. inject it into a 100 mL bag of saline
  3. now you have 100 mcg/mL.
  4. Put some in a 3 cc syringe.
  5. To give a 50 mcg dose, give 1/2 a cc.

What do you think?

REFERENCES:

* De Backer D, et al (SOAP II Investigators) Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM. March 4, 2010; 362(9): 779-89.
* EM-RAP: May 2010, Scott Weingard, MD and Mel Herbert, MD.

Inservice In The Break Room: Pressors

7 thoughts on “Inservice In The Break Room: Pressors

  1. Joyce asked: after 5ming start a drip if it works?I responded: Let me see if I understand your question. Do you mean for the push dose pressors? Those aren't given as a drip, but as one time pushes. You could give several.It basically buys you time for other things to work (get a line in, get the norepi drip mixed up, etc).

  2. 1. What is the drug of choice in the MICU? It makes sense to start whatever they will most likely be using up there, down here.2. Are there certain contraindications where you would want to use norepinephrine over phenylephrine or vice versa?3. Are both of these drugs readily available in our Pixes?

  3. Good point, Jane. The peds literature hasn't shown that norepi is any better than dopamine. Correct me if I'm wrong, but kids maintain their SVR much better than adults do, and so though they're in shock, they may maintain their blood pressure. Good question Meghan, maybe we can ask some of our deserters, er, I mean, ex-colleagues, who are now in the MICU, what they start.

  4. Yes, that lovely blue, mottled skin in the septic infant is a sign of a valiant attempt at keeping central pressure up by using that sytemic vascular resistance. Too bad it's a late and grave sign. I like this forum approach Rahul; thanks, it's a great idea. Jeff

  5. I was aware norepinephrine is a more potent vasoconstrictor than dopamine and has been found to be more effective than dopamine in restoring hemodynamic stability and is considered a first line coice of drug therapy for sepsis and thus should be using it more -along with fluids. I also read that since cortocosteroids may be helpful to decrease complement activity, platelet activation, TNF (not sure what this is)and proinflammatory cytokines , guidelines state that the use of corticosteroid is indicated for adulst with septic shock when hypotesnion remains poorly responsive to adequate fluid resuscitaion and vasopressors…Does the micu administer It? perhaps maybe we shoud give the first dose in Ed? any thoughts on this? It takes a while for steroids to kick in…right? also , Dr Patwari, whats your thoughts on the new category of meds (recombinant for of human activated protein C-Drotrecogin alfa)This is also recommended for patients with severe sepsis or septic shock who are at jigh risk for death. This acts on the body's response to infection at the level of the blood vessel…Trials have shown its use reduces risk of death among pattients with severe sepsis by 20% because it inhibits thombosis and infammation and promotes fibinolysis . It also prevents micorvsascular dysfunction and coagulation, improves tissue prefusion and oxygenation , and reverses hypotension…(nursing may/june 2009. so is this something we should also consider giving in er or is this more an micu drug to give. Is it too risky for us to give due to its antithromolytic effect? Sorry this is so long, but I recently read about septic shock and found some of this very interesting.

  6. Mary Kay, I think we should be using norepi more often. I think we fall back on dopamine out of habit and tradition. Though the consensus panel recommends using norepi, technically there are really no studies (I know of) that choose one over the other (perhaps one meta-analysis).Regarding steroids, I think the current guideline is if you've been hitting them hard with fluids and started norepi and that's not working, now you should be reaching for steroids and vasopressin. Also if your patient has recently been on steroids, consider it. Xigris (recomb activated Protein C-drotecgin alfa – now that's a mouthful) is pricey and not necessarily helpful. You also have to worry about people who are at risk for bleeding as this will worsen that. If we're using this, I'd say we consult with the intensivist. The way I read it is that it's a (pun intended) "hail Mary" pass. Things are going down and the patient is suffering from severe sepsis, then consider it. It is better given early, though. So the short answer is: ask the intensivist but possibly give in the ER. Great discussion, MaryK.

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