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BCPS Exam > Critical Care: Vasopressors in Sepsis > Flashcards

Critical Care: Vasopressors in Sepsis Flashcards

1
Q

When to initiate vasopressors in patients with sepsis?

A

Initiate vasopressors if the patient is hypotensive during or after fluid resuscitation to maintain MAP 65 mm Hg or greater

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2
Q

The goal MAP of 65 mm Hg should be ______, and should correlate with improvement in other __________.

A
  1. Individualized

2. Correlate with improvement in other clinical parameters.

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3
Q

List four clinical parameters that can help direct a MAP goal

A
  1. lactate concentration
  2. mental status
  3. urine output
  4. capillary refill
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4
Q

Give two example conditions that usually require a higher MAP goal in sepsis

A
  1. Atherosclerosis

2. History of hypertension

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5
Q

Ideally, vasopressors should be used ____ fluid resuscitation. However, in patients with septic shock, they may be needed _____ resuscitation to optimize perfusion of vital organs.

A
  1. After

2. During

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6
Q

Once intravascular volume is optimized with fluid resuscitation, vasopressors should be _______ if possible.

A
  1. Weaned
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7
Q

Vasopressors improve tissue perfusion by increasing _____ and/or _____

A
  1. Blood pressure

2. Cardiac Output

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8
Q

Drug selection of vasopressors is mostly based on what three types of evidence and information?

A
  1. Expert opinion
  2. Practitioner experience
  3. Patient response
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9
Q

Evidence for vasopressors tends to demonstrate differences in _______ rather than clinical outcomes

A

Safety

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10
Q

The pharmacology of vasopressors falls into two broad groups:

A
  1. Catecholamine

2. Non-catecholamine

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11
Q

List four catecholamine vasopressors

A
  1. Norepinephrine
  2. Epinephrine
  3. Phenylephrine
  4. Dopamine
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12
Q

List two non-catecholamine vasopressors

A
  1. Vasopressin

2. Angiotensin II

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13
Q

List three inotropes

A
  1. Moderate dose dopamine
  2. Dobutamine
  3. Milrinone
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14
Q

What is the primary hemodynamic effect of alpha 1, beta 1, and beta 2 recepotors?

A
  1. alpha 1: vasoconstriction
  2. beta 1: increased HR, increase contractility
  3. Beta 2: vasodilation, lactate production
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15
Q

What is the initial vasopressor of choice?

A

Norepinephrine

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16
Q

What is the place in therapy of epinephrine as a septic shock vasopressor?

A

added to or substituted for norepinephrine

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17
Q

What is the place in therapy of vasopressin as a septic shock vasopressor?

A

added to norepinephrine (or epinephrine) if needed

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18
Q

What is the place in therapy of dopamine as a septic shock vasopressor?

A

Alternative to norepinephrine with certain safety concerns

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19
Q

What is the place in therapy of phenylephrine as a septic shock vasopressor?

A
  1. Vasopressor-induced serious tachyarrhythmias or

2. persistent hypotension

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20
Q

What are the role of inotropes in septic shock?

A

Can be added to vasopressors for hemodynamic support

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21
Q

What is the place in therapy of Angiotensin II as a septic shock vasopressor?

A

Unclear at this time, was approved in 2017

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22
Q

What is unique about the receptor binding of dopamine?

A

Three binding affinities occuring at approximate dosing ranges

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23
Q

What are the three dosing types of dopamine?

A
  1. Low (renal)
  2. Moderate
  3. High
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24
Q

What is the receptor binding of norepinephrine?

A
  1. a1 ++++
  2. B1 ++
  3. B2 0
  4. DA 0
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25
Q

What is the receptor binding of epinephrine?

A
  1. a1 +++
  2. B1 ++
  3. B2 ++
  4. DA 0
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26
Q

What is the receptor binding of vasopressin?

A
  1. No adrenergic activity

2. Smooth muscle V1 vasopressin receptors causes vasoconstriction

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27
Q

What is the receptor binding of phenylephrine?

A
  1. a1 ++++
  2. B1 0
  3. B2 0
  4. DA 0
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28
Q

What is the receptor binding of Angiotensin II

A
  1. No adrenergic activity
  2. Binds to the G-protein coupled angiotensin receptor type 1 on vascular smooth muscle cells resulting in smooth muscle contraction, vasoconstriction
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29
Q

What is the receptor binding of low (renal) dose dopamine

A
  1. a1 +/- (minor effect)
  2. B1 +
  3. B2 +/-
  4. DA ++++
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30
Q

What is the receptor binding of moderate dose dopamine?

A
  1. a1 +
  2. B1 ++
  3. B2 0
  4. DA ++
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31
Q

What is the receptor binding of high dose dopamine?

A
  1. a1 +++
  2. B1 ++
  3. B2 0
  4. DA +
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32
Q

What is the receptor binding of dobutamine?

A
  1. a1 +
  2. B1 +++
  3. B2 +
  4. DA 0
33
Q

What is the receptor binding of milrinone?

A

Noncatecholamine, phosphodiesterase inhibitor

34
Q

List two hemodynamic effects of norepinephrine

A
  1. Increased SVR, increased MAP

2. No change or increase CO

35
Q

List three safety concerns of norepinephrine

A
  1. Decreased renal perfusion (blood flow)
  2. Peripheral ischemia, myocardial ischemia
  3. Tachyarrhythmias
36
Q

List four safety concerns of epinephrine

A
  1. Positive inotropic and chronotropic effects can induce (1) arrhythmias and (2) myocardial ischemia
  2. reduced splanchnic circulation may lead to gut ischemia
  3. Increased blood glucose
  4. Increase lactate (type B lactic acidosis)
37
Q

There is interest in vasopressin as a septic shock vasopressir because of an apparent relative ____ deficiency in ______.

A

Theoretically beneficial because of an apparent relative vasopressin deficiency in septic shock; but no evidence of efficacy over other vasopressors.

38
Q

Because vasopressin does not rely on adrenoreceptors, it has a special role during ____ and _____.

A
  1. Acidosis

2. Hypoxia

39
Q

What is the safety concern of increases dosing of vasopressin?

A

Doses greater than or equal to 0.04 unit/min are associated with coronary vasoconstriction and peripheral necrosis

40
Q

Vasopressin is prone to dosing errors: why?

A

Dosed in unit/min instead of mcg/min like other vasopressors.

41
Q

Compare the titration of vasopressin to traditional vasopressors

A

Vasopressin is typically dosed as a flat dose (e.g. 0.03 unit/min) without bedside titration.

42
Q

Describe hemodynamic effects of phenylephrine

A
  1. Increased SVR, increased MAP

2. Can cause reduction in CO due to rapid increase in SBP and DBP causing reflex bradycardia.

43
Q

List a safety side effect of phenylephrine

A

Decreased renal perfusion

44
Q

List two ways to administer phenlephrine

A
  1. Rapid bolus

2. Continuous infusion

45
Q

Phenylephrine is a pure ____-adrenergic agonist with minimal ____ activity, and can be administered as a rapid bolus for ________ in ___operative setting.

A
  1. Pure alpha-adrenergic agonist with
  2. Minimal cardiac activity
  3. Rapid bolus for intraoperative setting.
46
Q

Recent exposure to angiotensin-converting enzyme (ACE) inhibits may cause an _______ response to angiotensin II

A

Exaggerated

47
Q

Recent exposure to angiotensin II receptor blockers (ARBs) may cause a _____ response to angiotensin II

A

Reduced

48
Q

List five safety concerns of angiotensin II

A
  1. Increased risk of thrombotic events (mechanical and pharmacologic thromboprophylaxis is recommended)
  2. Increased heart rate
  3. Lactic acidosis
  4. Infections (e.g. fungal)
  5. Delirium
49
Q

List five physiologic effects of low (renal) dose dopamine

A
  1. Renal vasodilation
  2. Coronary vasodilation
  3. Mesenteric vasodilatiaon
  4. Cerebral arterial vasodilation
  5. Natriuretic response
50
Q

List two hemodynamic effects of moderate dopamine doses

A
  1. Increase contractility

2. Increase SVR

51
Q

Low/moderate inotropic dopamine doses can ____ the vasoconstrictive effects of norepinephrine

A

Complement

52
Q

Dopamine effects on renal blood flow may be _____ at higher doses because of predominant _______ effects

A
  1. Lost

2. Predominant alpha-1 vasoconstrictive effects

53
Q

List two safety concerns of dopamine that can occur at any dose

A
  1. Arrhythmias

2. Endocrine changes (decreased prolactin, growth hormone, thyroid hormone)… clinical significance unknown

54
Q

Dopamine is the immediate precursor of ______

A

Norepinephrine

55
Q

_____ infusions of dopamine can deplete endogenous _____ stores, resulting in a loss of ______ response

A

Prolonged infusions of dopamine can deplete endogenous norepinephrine stores, resulting in a loss of vasopressor response.

56
Q

What is the hemodynamic effect of dobutamine?

A

Positive inotrope to increase cardiac output

57
Q

List two safety concerns of dobutamine

A
  1. Hypotension because of Beta-2 stimulation

2. Higher doses can cause myocardial ischemia and tachyaarrhythmias and changes in BP

58
Q

What is the hemodynamic effect of milrinone?

A

Positive inotrope to increase cardiac output

59
Q

List two safety concerns of milrinone

A
  1. Vasodilation or hypotension

2. Arrhythmias

60
Q

How to change milrinone dose in a patient with renal impairment?

A

Use lower doses in renal impairment

61
Q

How to change milrinone dose in a patient with hypotension?

A

Loading dose often omitted

62
Q

Describe the SOAP II trial (Hint: design, efficacy, safety, implication)

A
  1. Landmark, multicenter randomized trial of patients requiring vasopressors because of any type of shock.
  2. Enrolled patients received blidned norepinephrine or dopamine
  3. No difference in 28-day mortality
  4. Safety: dopamine commonly developed arrhythmias, required open-label norepinephrine, and required more days with vasopressor support.
  5. Suggest norepinephrine does not improve mortality but is safer and more effective.
63
Q

Describe the role and efficacy of vasopressin with norepinephrine

A
  1. The efficacy of vasopressin when added to norepinephrine is similar to that of norepinephrine alone. No improvement in mortality.
  2. May have vasopressor-sparing effect when used early, at norepinephrine doses lower than 15 mcg/min. May be associated with improved outcomes.
64
Q

Dopamine use should be limited as an alternative to norepinephrine in patients with two factors:

A
  1. Low risk of tachyarrhythmias

2. Absolute or relative bradycardia

65
Q

Low-dose dopamine should not be used for ____ protection

A

Renal protection

66
Q

What is the preferred method of measuring blood pressuring in a patient needing vasopressor, and why?

A
  1. Use an arterial catheter for blood pressure measurements

2. More accurate (compared to cuff) and allows continuous monitoring

67
Q

Vasopressors should be administered through a central line as soon as possible to reduce the risk of _____ and subsequent tissue ______.

A
  1. Extravasation

2. Subsequent tissue ischemia

68
Q

What to do if vasopressor extravasates?

A
  1. Stop the vasopressor immediately, and switch to another site if necessary.
  2. Apply an antagonist/antidote.
69
Q

List three “antidotes” to vasopressor extravasation

A
  1. SubQ Phentolamine (alpha-receptor antagonist)
  2. Nitroglycerin ointment (applied topically every 6 hours)
  3. SubQ Terbutaline (beta-2 receptor agonism)
70
Q

What is the FDA-approval for Angiotensin II?

A
  1. Increase blood pressure in adults with septic shock

2. Increase blood pressure in adults with distributive shock.

71
Q

Typical dosing range of norepinephrine?

A

0.01-3 mcg/kg/min

72
Q

Typical dosing range of epinephrine?

A

0.04-1 mcg/kg/min

73
Q

Typical dosing range of vasopressin

A

0.03-0.04 units/min (not weight based, not titrated)

74
Q

Typical dosing range of phenylephrine

A

0.5-8 mcg/kg/min

75
Q

Typical dosing range of Angiotensin II

A

Initial (during first 3 hr of treatment) 10-80 ng/kg/min

Maintenance: 1.25-40 ng/kg/min

76
Q

Typical dosing range of dopamine

A

1-3 mcg/kg/min

77
Q

Typical dosing range of dobutamine

A

2-20 mcg/kg/min

78
Q

Typical dosing range of milrinone

A

Loading dose: 50 mcg/kg loaded over 10 minutes

Followed by: 0.375-0.75 mcg/kg/min

BCPS Exam (34 decks)

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