1. Vasopressors and Inotropes in Canadian Emergency Departments
Dennis Djogovic MD, FRCPC

2. Financial Disclosures
None to declare

3. VICE has created a document to address that
ER docs treat shock
There are no evidence based guidelines to assist in which pressor/trope to use in shock
VICE has created a document to address that
CAEP standards committee
CJEM

4. VICE squad Shavaun MacDonald Rob Green Andrea Wensel Osama Loubani
James Lee Patrick Archambault
Janeva Kircher Simon Bordeleau
Katherine Smith Adam Szulewski
Jon Davidow Sara Gray
Dennis Djogovic Jean Marc Benoit
David Messenger
Dan Howes

5. What is Shock?

6. What are the types of shock?
Cardiogenic
Obstructive
Distributive
Hypovolemic

7. What are vasopressors? Systemic vasoconstriction
Pulmonary vasoconstriction
Increase Mean Arterial Pressure (MAP)

8. What are inotropes? Agents that increase cardiac output
Increase inotropy
Increase chronotropy
Decrease afterload

9. Inotropes Vasopressors
Intra aortic Balloon Pump Phenylephrine Dobutamine Ephedrine Isoproteronol Norepinephrine Epinephrine Dopamine Milrinone Nitroprusside Digoxin

10. Different shock types need different managment
Guidelines based on different shock types

11. Research methodology (only one slide!)
AGREE II
PICO questions
Section authors/literature review
GRADE
Quality of evidence
Strength of recommendation
Delphi consensus process

12. 1040 articles in focused article list
articles identified
1040 articles in focused article list
113 articles used for grading purposes
7 clinical questions
18 recommendations
5 strong
13 conditional

13. Quality of Evidence A= High Level of evidence B= Moderate C= low
Good RCT
B= Moderate
Poor RCT, well done observational series
C= low
Poor observational series
D= very low
Case series, expert opinion

14. Strength of Recommendation
Balance desirable and undesirable effects
Quality of evidence
Values and preferences
costs

15. Strength of Recommendation
Strong
Conditional
70% of votes needed for “Strong” recommendation

16. Question 1: For ED patients in shock, what are the side effects of vasopressors and inotropes?
Dopamine increases the risk of tachyarrhythmia compared to norepinephrine. (Grade A).
Dopamine use in septic shock increases mortality compared to norepinephrine (Grade B).
Vasopressin as a first line vasopressor may be associated with cellular ischemia and skin necrosis, particularly when combined with sustained moderate to high dose infusions of norepinephrine. (Grade C).

17. Epinephrine increases metabolic abnormalities compared to norepinephrine. (Grade A).
Epinephrine increases metabolic abnormalities compared to norepinephrine-dobutamine in cardiogenic shock without acute cardiac ischemia. (Grade B).

18. Question 2: Which vasopressors and inotropes should be used in the treatment of ED patients with cardiogenic shock?
Recommendation: Cardiogenic shock patients in the ED should receive norepinephrine as the first-line vasopressor. (Strong)

19. Question 2: Which vasopressors and inotropes should be used in the treatment of ED patients with cardiogenic shock?
Recommendation: Cardiogenic shock patients in the ED should receive dobutamine if an inotrope is deemed necessary. (Conditional)

20. Question 3: Which vasopressors and inotropes should be used in the treatment of ED patients with hypovolemic shock?
Recommendation: Routine vasopressor use in hypovolemic shock is not recommended. (Conditional)

21. Recommendation: Vasopressin may be indicated in hemorrhagic or hypovolemic shock if a vasopressor is deemed necessary. (Conditional)

22. Question 4: Which vasopressors and inotropes should be used in ED patients with obstructive shock?
Recommendation: In obstructive shock not responding to indicated treatment, a systemically active vasopressor should be instituted.  (Conditional)

23. Question 4: Which vasopressors and inotropes should be used in ED patients with obstructive shock?
Recommendation: For patients with known or suspected hypertrophic obstructive cardiomyopathy (HOCM) or dynamic outflow obstruction, inotropic agents should be avoided. Judicious use of vasoconstrictive agents can be considered. (Conditional)

24. Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?
Recommendations: Norepinephrine is the first line vasopressor for use in septic shock. (Strong)

25. Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?
Recommendation: Vasopressin should be considered in catecholamine refractory septic shock. (Conditional)

26. Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?
Recommendation: Dobutamine should be used for septic shock with low cardiac output despite adequate volume resuscitation. (Strong)

27. Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?
Recommendation: Vasopressor choice in neurogenic shock is not clear. The agent should be determined by patient characteristics and response to treatment. (Conditional)

28. Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?
Recommendation: Norepinephrine is the first line agent for the management of distributive shock due to hepatic failure. (Conditional)

29. Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?
Recommendation: Epinephrine infusion is the preferred agent for anaphylactic shock that does not respond to intramuscular or intravenous bolus epinephrine. (Strong)

30. Question 5: Which vasopressors and inotropes should be used in ED patients with distributive shock?
Recommendation: Vasopressor choice in distributive shock secondary to adrenal insufficiency not responding to steroid replacement is not clear. Patient response to chosen agents should guide therapy. (Conditional)

31. Question 6: Which vasopressors and inotropes should be used in ED patients with undifferentiated shock?
Recommendation: In undifferentiated shock not responding to fluid resuscitation, norepinephrine should be the first-line vasopressor. (Strong)

32. Question 6: Which vasopressors and inotropes should be used in ED patients with undifferentiated shock?
Recommendation: In undifferentiated shock, a second vasopressor should be added if a goal MAP>70mmHg is not being achieved. (Conditional)

33. Question 7: How should vasopressors and inotropes be administered to ED patients?
Recommendation: Short term vasopressor infusions (<1-2 hours) or boluses via properly positioned and functioning peripheral intravenous catheters are unlikely to cause local complications. (Conditional)

34. Question 7: How should vasopressors and inotropes be administered to ED patients?
Recommendation: Vasopressor infusions for prolonged periods (>2-6 hours) should preferentially be administered via central venous catheters. (Conditional)

35. Question 7: How should vasopressors and inotropes be administered to ED patients?
Recommendation: Inotropes can be given via peripheral catheter (short term) or central venous catheters (prolonged period) with a similarly low incidence of local complications. (Conditional)

36. Question 7: How should vasopressors and inotropes be administered to ED patients?
Recommendation: The administration of vasopressors via intra-osseous lines is safe in adults. (Conditional)

37. Question 7: How should vasopressors and inotropes be administered to ED patients?

38. In summary Identify the type of shock Norepi > dopamine
To determine the type of treatment
Norepi > dopamine
Cross your fingers!