Vasopressor Use

[jjones1418]

I guess I should have been more clear. I see that from the responses, basically everyone carries Dopamine, and a few utilize Epinephrine, Dobutamine, Levophed, or Vasopressin.

What I was looking for, is when you use a particular vasopressor. Do you have the freedom to choose if the patient condition, in your opinion, needs a different vasopressor? For example, "This patient has X, I can go with A, B, or C." If so, what do you look for in your clinical assessment to choose an agent?

Or, are you dictated by protcol, that you use X for Y and A for B?

[jjones1418]

I'm not seeing much IABP use here, but most of the patients I see are from smaller hospitals. We're usually taking them to places that can place IABPs. I'm sure they're being used. I'll have to ask a few of our nurses that work at the larger hospitals.

I don't know of a ground EMS service around here that HAS a balloon pump, but they do transport patients with them. Some of the metroplex hospitals can place them and use the CCT trucks for transport to different hospitals.

[Dustdevil]

Do you have the freedom to choose if the patient condition, in your opinion, needs a different vasopressor? For example, "This patient has X, I can go with A, B, or C." If so, what do you look for in your clinical assessment to choose an agent?

Or, are you dictated by protcol, that you use X for Y and A for B?

We have Epi, Vasopressin, and Dopamine. Each is used according to whatever the clinician feels is appropriate for the patient. There are no specific, cookbook type protocols which spell out what must be used for what situations. However, with that freedom comes responsibility. You had better be able to explain when the medical director calls, exactly why you chose that agent, pharmacologically and physiologically speaking. And your explanation had better go a lot farther than "well, that's what ACLS says" or "that's the way we've always done it."

I had a lot of pharm education before I went to medic school, so I already had a bit of insight. So when I got to firemonkey medic school and they were teaching levarterenol, I was pretty surprised, as it had already fallen out of favour years earlier. I haven't used it since around 1984. Interesting that it is making a comeback. Dallas FD will be happy to hear that, as it has remained their one and only agent for thirty years now.

Dopamine is a good choice for EMS overall because its mechanism of action is dependent upon its dosage, making it very utilitarian, unlike those agents that are strictly alpha or beta.

[Spock]

We carry dopamine and dobutamine premix on the truck and could mix an epi drip if needed. We don't carry levophed but I do use it in the OR if the SVR is low. I'm trained as a cardiac anesthetist so I prefer epi. Dopamine just makes them tachycardic at low doses and dobutamine is a great vasopressor when you don't need one. That's why I like epi. Put 4mg of 1::1000 in a 250cc bag and run at 15cc/hr which gives you 4 mcg/min. If you can't run with the big dogs stay on the porch!

We use vasopressin or isuprel as last ditch pressors. Those patients do not do well.

Live long and prosper.

Spock

[jjones1418]

Thanks dust. That's what kind of replies I was looking for.

Also, I believe Dallas has Dopamine now, not that they will ever use it. It's in Biotel's protocols on their website. I know Farmers Branch has it, as I have a few friends that work there, and they're Biotel. Also, there are a few different sets of protocols in Biotel, but I think they just recently added the Dopamine, say in the last year or two. I couldn't work in that system. These poor guys have to call after the 2nd round of meds in a cardiac arrest...

"Umm, yeah. He's still dead... What now?"

[Doczilla]

Norepi (levophed) Strong alpha agonist with some beta effects. Some folks will say this is the DOC for septic shock after fluid resuscitation. My first line for shock with a low CVP.

Dopamine. As Dust said, it's a good all around pressor. Inotropic and chronotropic at low-mid doses, vasoconstrictor at higher doses. Good choice for cardiogenic shock. May be considered in septic shock because there is some depressed inotropy with sepsis (more prevalent in kids). Important to note that it works by stimulating release of norepi, and may not work if the patient's norepi stores are low.

Epi. Popular drug in kids. DOC in multiphasic anaphylaxis when the patient needs to be sustained on something. Not a big fan of this in adults otherwise. Okay for sepsis and other forms of shock. Some evidence to support its use in massive pulmonary embolus.

Phenylephrine (Neosynephrine). Pure vasoconstrictor. Good for shock states from vasodilation such as spinal shock. Also used frequently in septic shock.

Vasopressin. Vasoconstrictor. I don't use this very much, to be honest. Other good choices which are cheaper.

Dobutamine. Pure inotrope. Doesn't really increase BP. Good for the pt. in CHF who has a normal BP. Otherwise, I don't use it much.

Milrinone. Phosphodiesterase inhibitor. Essentially does the same thing as dobutamine but doesn't require a beta receptor to work. No evidence supporting its use over dobutamine, and much more expensive. I never use this except in beta blocker overdose.

Glucagoon. Not routinely used as a pressor except for beta blocker or calcium channel blocker overdose. That's about the only time I whip this out, and usually at very large doses.

So in summary I use:

Cardiogenic shock: dopamine

Dopamine not working: add norepi

Sepsis or suspected sepsis: norepi

Spinal shock: norepi or phenylephrine

Anaphylaxis: epi

Kids: epi

Beta blocker or calcium channel blocker OD: glucagon +/- milrinone

Most important to remember: FLUID!

'zilla

[akroeze]

Doc:

If you could only have one pressor to hang on a live patient what would it be? In other words you have no clue what may be thrown at you, what would you consider the best "jack of all trades"?

For reference, here in Ontario the only pressor we hang is Dopamine.

[Doczilla]

I agree with dopamine.

'zilla

[bryan20w]

Just out of curiosity doesn't milrinone also decrease vascular resistance?

[Spock]

You are correct about milrinone since it is a potent vasodilator. I can only remember one time where I gave a loading dose of milrinone and did not have to run an epi infusion.

Live long and prosper.

Spock