John Greenwood discusses the use of vasopressors in the emergency room. His talk focuses on three areas. First, he reviews vasopressors and categorises them based on resuscitation end points. Secondly, he addresses the concept of “pressor angst” and how it can significantly impact patient mortality. Finally, he will empower you to start vasopressors early in patients with distributive shock and sepsis. The tale of a 45-year-old lady with sepsis in the context of pneumonia is retold. John asks - what do you do? Initial fluid resuscitation has improved the vitals somewhat, but she is still hypotensive. Continue to give fluids? Sure – it seems to be what happens commonly. Starting vasopressors starts a cascade of events that will consume time and resources. It impacts flow, timing and ability to see other patients. Often, the clinician knows it the right thing to do but does not want to pull the trigger. This process of having two conflicting beliefs in your brain at the same time is cognitive dissonance. In the context of using vasopressors, John terms this “pressor angst”. The hesitation to use vasopressors even when perhaps you know it is the right thing to do. It is a complex confliction of behaviours, beliefs, goals, and practices. Regarding vasopressors specifically, the clinician will be considering the logistics, bed crunch and procedures amongst other things! Why does the time matter? As John explains with reference to the literature, the time to the decision to commence vasopressors is hugely important in influencing patient mortality. There is a clear mortality benefit to starting vasopressors early. Norepinephrine started early can aid in adjusting preload, cardiac output, and afterload parameters. John steps you through the effect of norepinephrine on all metrics that contribute to. The conclusion is that early norepinephrine administration improves both macro- and microcirculatory function in vasoplegic shock. John wants you to avoid pressor angst! Do not be afraid of vasopressors and pull the trigger early. Finally, consider norepinephrine early in sepsis.

1. Practical Approach to Vasoactives
Avoiding the Cognitive Dissonance of Pressor
Angst
John C. Greenwood, MD
Emergency Medicine
Critical Care Medicine
University of Pennsylvania
Philadelphia, PA USA
@JohnGreenwoodMD

2. Goals
1. Review vasopressors & categorize them
based on resus end-points.
2. Discuss the concept of “Pressor Angst” &
how it could significantly impact patient
mortality.
3. Empower you to start vasopressors EARLY
in patients with distributive shock.

3. 45 y/o female presenting with PNA.
VS: 39.5 110 101/38 [59] 22 92% 5L NC
LA: 6 4 mmol/dL, post-30 cc/kg IVF

5. Cognitive
Dissonance
Attitudes
Customs
Goals
Practices
Beliefs
Behaviors
Thoughts
Evidence

6. Pressor
Angst
Procedures
Bed Crunch
Logistics
Charge
Nurse
Disposition
Fluids
Necessary?
End points

7. Pressor Angst
Varpula, 2005 Dunser, 2009 Bai, 2014Varpula, 2005 Dunser, 2009 Bai, 2014
For each hour delay in
NE initiation (within the
first six hours), the
mortality rate increased
by 5.3%.

8. Peripheral Pressors are SAFE
18-20g AC line
Loubani OM et al. J Crit Care 2015; 30 (3): 653.e9 – 653.e17.
Ricard JD et al. Crit Care Med 2013; 41: 2108 – 15.
Cardenas-garcia J, et al. J Hosp Med. 2015;10(9):581-5.

9. Hypovolemic Cardiogenic
Obstructive
Trauma
GIBc.diff
Vomiting
Post-op
DI
STEMI Arrhythmia
Regurgitation
Myocarditis
Diastolic
dysfunction
PE
Tamponade
HOCM
PTX
PHTN Sepsis
Anaphylaxis
Pancreatitis
Post-CPB
Neuro
DistributiveDistributive
De backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the
treatment of shock. N Engl J Med. 2010;362(9):779-89.

10. Hypovolemic Cardiogenic
Obstructive Distributive
Patient

11. Macro-/Microcirc Targets

12. Tank Pump Pipes

13. Preload CO Afterload

14. Volume PressorInotrope
Preload CO Afterload

15. Norepinephrine
ˈnȯr-ˌe-pə-ˈne-frən

17. MAPPPVCVPGEDVISVI NE
Hamzaoui O, 2010. Monnet X, 2010.
Preload
CO
Afterload
[α β1]

18. NE
Hamzaoui O, 2010. Monnet X, 2010.
Preload
CVP
PPV
SVI
GEDVI
CO
MAP
Afterload
[α β1]

19. Early NE administration improves
both Macro- & Microcirculatory
function
in vasoplegic shock.

21. Trigger for early NE:
DAP < 40 mmHg
Signal of significant vasoplegia
venous maldistribution, &
unstressed intravascular volume
Monnet X, 2011.

22. NE on
NE off

23. Final Points
• Delays in vasoactive administration
for septic shock associated with
significant increase in mortality.
• Consider NE early in sepsis.
Improves preload, improves
microcirculation, limits fluid
administration.