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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
What is the receptor binding of epinephrine?
1. a1 +++ 2. B1 ++ 3. B2 ++ 4. DA 0
26
What is the receptor binding of vasopressin?
1. No adrenergic activity | 2. Smooth muscle V1 vasopressin receptors causes vasoconstriction
27
What is the receptor binding of phenylephrine?
1. a1 ++++ 2. B1 0 3. B2 0 4. DA 0
28
What is the receptor binding of Angiotensin II
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
29
What is the receptor binding of low (renal) dose dopamine
1. a1 +/- (minor effect) 2. B1 + 3. B2 +/- 4. DA ++++
30
What is the receptor binding of moderate dose dopamine?
1. a1 + 2. B1 ++ 3. B2 0 4. DA ++
31
What is the receptor binding of high dose dopamine?
1. a1 +++ 2. B1 ++ 3. B2 0 4. DA +
32
What is the receptor binding of dobutamine?
1. a1 + 2. B1 +++ 3. B2 + 4. DA 0
33
What is the receptor binding of milrinone?
Noncatecholamine, phosphodiesterase inhibitor
34
List two hemodynamic effects of norepinephrine
1. Increased SVR, increased MAP | 2. No change or increase CO
35
List three safety concerns of norepinephrine
1. Decreased renal perfusion (blood flow) 2. Peripheral ischemia, myocardial ischemia 3. Tachyarrhythmias
36
List four safety concerns of epinephrine
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
There is interest in vasopressin as a septic shock vasopressir because of an apparent relative ____ deficiency in ______.
Theoretically beneficial because of an apparent relative vasopressin deficiency in septic shock; but no evidence of efficacy over other vasopressors.
38
Because vasopressin does not rely on adrenoreceptors, it has a special role during ____ and _____.
1. Acidosis | 2. Hypoxia
39
What is the safety concern of increases dosing of vasopressin?
Doses greater than or equal to 0.04 unit/min are associated with coronary vasoconstriction and peripheral necrosis
40
Vasopressin is prone to dosing errors: why?
Dosed in unit/min instead of mcg/min like other vasopressors.
41
Compare the titration of vasopressin to traditional vasopressors
Vasopressin is typically dosed as a flat dose (e.g. 0.03 unit/min) without bedside titration.
42
Describe hemodynamic effects of phenylephrine
1. Increased SVR, increased MAP | 2. Can cause reduction in CO due to rapid increase in SBP and DBP causing reflex bradycardia.
43
List a safety side effect of phenylephrine
Decreased renal perfusion
44
List two ways to administer phenlephrine
1. Rapid bolus | 2. Continuous infusion
45
Phenylephrine is a pure ____-adrenergic agonist with minimal ____ activity, and can be administered as a rapid bolus for ________ in ___operative setting.
1. Pure alpha-adrenergic agonist with 2. Minimal cardiac activity 3. Rapid bolus for intraoperative setting.
46
Recent exposure to angiotensin-converting enzyme (ACE) inhibits may cause an _______ response to angiotensin II
Exaggerated
47
Recent exposure to angiotensin II receptor blockers (ARBs) may cause a _____ response to angiotensin II
Reduced
48
List five safety concerns of angiotensin II
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
List five physiologic effects of low (renal) dose dopamine
1. Renal vasodilation 2. Coronary vasodilation 3. Mesenteric vasodilatiaon 4. Cerebral arterial vasodilation 5. Natriuretic response
50
List two hemodynamic effects of moderate dopamine doses
1. Increase contractility | 2. Increase SVR
51
Low/moderate inotropic dopamine doses can ____ the vasoconstrictive effects of norepinephrine
Complement
52
Dopamine effects on renal blood flow may be _____ at higher doses because of predominant _______ effects
1. Lost | 2. Predominant alpha-1 vasoconstrictive effects
53
List two safety concerns of dopamine that can occur at any dose
1. Arrhythmias | 2. Endocrine changes (decreased prolactin, growth hormone, thyroid hormone)... clinical significance unknown
54
Dopamine is the immediate precursor of ______
Norepinephrine
55
_____ infusions of dopamine can deplete endogenous _____ stores, resulting in a loss of ______ response
Prolonged infusions of dopamine can deplete endogenous norepinephrine stores, resulting in a loss of vasopressor response.
56
What is the hemodynamic effect of dobutamine?
Positive inotrope to increase cardiac output
57
List two safety concerns of dobutamine
1. Hypotension because of Beta-2 stimulation | 2. Higher doses can cause myocardial ischemia and tachyaarrhythmias and changes in BP
58
What is the hemodynamic effect of milrinone?
Positive inotrope to increase cardiac output
59
List two safety concerns of milrinone
1. Vasodilation or hypotension | 2. Arrhythmias
60
How to change milrinone dose in a patient with renal impairment?
Use lower doses in renal impairment
61
How to change milrinone dose in a patient with hypotension?
Loading dose often omitted
62
Describe the SOAP II trial (Hint: design, efficacy, safety, implication)
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 3. Safety: dopamine commonly developed arrhythmias, required open-label norepinephrine, and required more days with vasopressor support. 4. Suggest norepinephrine does not improve mortality but is safer and more effective.
63
Describe the role and efficacy of vasopressin with norepinephrine
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
Dopamine use should be limited as an alternative to norepinephrine in patients with two factors:
1. Low risk of tachyarrhythmias | 2. Absolute or relative bradycardia
65
Low-dose dopamine should not be used for ____ protection
Renal protection
66
What is the preferred method of measuring blood pressuring in a patient needing vasopressor, and why?
1. Use an arterial catheter for blood pressure measurements | 2. More accurate (compared to cuff) and allows continuous monitoring
67
Vasopressors should be administered through a central line as soon as possible to reduce the risk of _____ and subsequent tissue ______.
1. Extravasation | 2. Subsequent tissue ischemia
68
What to do if vasopressor extravasates?
1. Stop the vasopressor immediately, and switch to another site if necessary. 2. Apply an antagonist/antidote.
69
List three "antidotes" to vasopressor extravasation
1. SubQ Phentolamine (alpha-receptor antagonist) 2. Nitroglycerin ointment (applied topically every 6 hours) 3. SubQ Terbutaline (beta-2 receptor agonism)
70
What is the FDA-approval for Angiotensin II?
1. Increase blood pressure in adults with septic shock | 2. Increase blood pressure in adults with distributive shock.
71
Typical dosing range of norepinephrine?
0.01-3 mcg/kg/min
72
Typical dosing range of epinephrine?
0.04-1 mcg/kg/min
73
Typical dosing range of vasopressin
0.03-0.04 units/min (not weight based, not titrated)
74
Typical dosing range of phenylephrine
0.5-8 mcg/kg/min
75
Typical dosing range of Angiotensin II
Initial (during first 3 hr of treatment) 10-80 ng/kg/min Maintenance: 1.25-40 ng/kg/min
76
Typical dosing range of dopamine
1-3 mcg/kg/min
77
Typical dosing range of dobutamine
2-20 mcg/kg/min
78
Typical dosing range of milrinone
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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