Resuscitating the Hypotensive Patient
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This document discusses the resuscitation of hypotensive patients through fluid resuscitation and vasoactive medications. It defines shock, outlines the epidemiology and diagnosis of shock, and explains how to assess shocked patients both physically and through laboratory tests like lactate levels. Fluid resuscitation is presented as the initial treatment, followed by vasoactive agents if fluids fail to improve the patient's condition. Examples of inotropes, vasopressors, and push dose pressors are provided, along with their indications and mechanisms of action. Finally, case studies demonstrate the application of specific vasoactive medications in anaphylaxis, sepsis, post-intubation hypotension, and cardiogenic shock.
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Resuscitating the Hypotensive Patient
- 1. Resuscitating the Hypotensive Patient Kane Guthrie FCENA
- 2. Hypotensive Resuscitation • Look at shock • Fluid resuscitation • Pharmacology of vasoactive medications • Current evidence • Case Studies
- 3. Shock Inadequate oxygen delivery to meet tissue demands
- 7. Diagnosing Shock 3 components • Systemic arterial hypotension • Clinical signs tissue hypoperfusion • Hyperlactatemia
- 9. Hypotension in ED • Independently predicts in-hospital mortality • Risk of death increases: • SBP <80mmHg • Sustained hypotension >60min
- 11. Hypotension Predicts Mortality • Pulmonary Embolism • Myocardial Infarction • Traumatic Brain Injury • Sepsis
- 12. Assessing the Shocked Patient • Physical exam can assess overall tissue perfusion: • Assess mental status • • Assess skin • • Are patients confused?, dizzy?, drowsy? Is the skin cool or mottled? Assess kidney perfusion • Is urine output less than 0.5 mL/kg/hour?
- 13. Laboratory Assessment • Laboratory testing can be used to assess perfusion: • Elevated serum creatinine • • Elevated liver function tests • • This signifies reduced organ perfusion This signifies reduced organ perfusion Oxygen saturation of venous blood • SVO2
- 14. Checking Lactate • Marker end organ perfusion • End product – anaerobic metabolism • Lactate >4 = panic value • Lactate normalisation
- 15. Using CVP • Poor evidence behind recommendations • 8-12mmHg is ideal range • >15 mmHg if ventilated • <8mmHg & hypotensive = fluids
- 16. Measuring IVC Full non-collapsing IVC = Pt adequately filled.
- 17. Fill the Tank
- 18. Fluid Resuscitation • Improve microvascular blood flow • Increase cardiac output • May benefit cardiogenic shock • Fluid maldistribution
- 19. What fluid & How Much? • Crystalloid –first choice • Albumin in certain patients! • Boluses 500ml-1tre every 20-30mins
- 20. Monitoring Fluid Resuscitation • ^ systemic arterial pressure • < heart rate • ^ urine output
- 21. When Fluids Fail
- 22. Vasoactive Agents • Used to optimise: • End-organ perfusion • Oxygen delivery
- 23. Inotrope(s) • Increase the force & velocity of myocardial contraction with increased contraction, stroke volume & cardiac output.
- 24. Inotropes • Examples: • Adrenaline • Dobutamine • Isoprenaline
- 25. Vasopressor(s) • Increase vascular tone with raised MAP & SVR.
- 26. Vasopressor(s) • Noradrenaline • Vasopressin • Dopamine
- 27. Push Dose Pressor • Short acting vasopressor that works through potent & selective alpha stimulation.
- 28. Push Dose Pressor • Metaraminol • Adrenaline • Ephedrine
- 29. The Hard Evidence! • No agent has shown to have superiority over any others in good quality studies!
- 30. Use Based On • Cost • Availability • Interpretation of physiology • Personal/physician preference • Institutional preference
- 31. Target Receptors • Alpha 1- vasoconstriction, ^ SVR • Alpha 2 – smooth muscle contraction • Beta 1 – positive chronotrope/inotrope, ^HR, ^contractility • Beta 2 – induce vasodilatation
- 33. CVC • Preferred • IVC till bridge to CVC
- 34. Do We Always Need CVC?
- 35. Indications • Fluid resuscitation = failed • Persistent hypotension • Improve contractility & cardiac output
- 37. Forget BP –Focus MAP • Mean arterial pressure MAP = CO x SVR • Target MAP >65mmHg • Chronic hypertension aim higher • Measure adequate tissue perfusion
- 38. Case 1
- 39. Case 1 • What vasoactive medication is indicated?
- 40. Adrenaline • Alpha & beta adrenergic properties • Treats 3 aspects of anaphylaxis • Laryngeal oedema • Bronchospasm • Shock
- 41. Adrenaline Actions • Vasoconstriction • Reduction - mucosal oedema • Bronchodilation • Increased myocardial contractility
- 42. Case 1 • What dose and route would you give it?
- 43. Case 1 • Adult 0.3-0.5mg (1mg/ml) • IMI (lateral thigh) • Rpt as needed - consider infusion.
- 44. Case 2
- 45. Case 2 • What vasoactive medication is indicated?
- 46. Noradrenaline • Surviving Sepsis Guidelines 2013 • Norad = vasoconstriction - HR + contractility. • 6mg 100mls or 3mg 50mls 5% Dextrose
- 48. Case 3
- 49. Postintubation Hypotension • Occurs in 23% of ED intubations • Vasodilation of induction agents
- 50. Case 3 • What vasoactive medication is indicated?
- 51. Push Dose Pressors • Metaraminol 10mg/ml (mix in 20mls) • Sympathomimetic amine • increases systolic/diastolic BP • Short acting 3-10min
- 52. Case 4
- 53. Cardiogenic Shock • Results from primary cardiac dysfunction • MI • papillary muscle/ventricular septal rupture, left ventricle dysfunction
- 54. Case 4 • What vasoactive medication is indicated?
- 55. Inotropes • Dobutamine • Beta 1 effects - cardiac contractility • Beta 2 effects - reduce afterload • Refractory consider adding Noradrenaline
- 56. Take Home Points • Shock/hypotension is common • Fluids often fail • Be familiar with indications, dose & pharmacology for vasoactive meds
- 57. Thankyou