- All right.
Thanks for coming back, you guys, I appreciate it.
Today I really wanna cover IV vasoactive medications,
so you know how to handle this.
Generally when we talk about this,
we're talking about pressers, people say pressers,
but we're also gonna talk about some medications
that we consider inotropes,
meaning they make your heart squeeze better,
as opposed to just pressing down your blood vessels,
so I like referring to them as vasoactive medications, okay?
First thing I wanna say, we have a patient in shock,
the first thing we wanna try,
unless we know the patient has cardiogenic shock,
the first thing we're gonna do is fluids.
So what I'm talking about here,
all these things that are gonna happen
are gonna happen generally after we do fluids.
Okay, so that's for step one.
After we do fluids and we don't get
their main arterial blood pressure to 65,
then we talk about putting patients
on these various medications, okay?
So always thing about MAP greater than 65
is really gonna be your goal for most diagnoses.
Okay, is that cool?
All right, so really what I wanna do, is go through
the different medications, what receptors they affect
and when we wanna use them, okay.
So there's three big kind of receptors,
that we think about these affecting.
One is called the Alpha-1 receptor.
You guys know what Alpha-1 receptors do?
Yeah, so they squeeze blood vessels.
So I think of that as increasing blood pressure.
Okay, then we have Beta-1, what do Beta-1 do?
Yeah, so this is inotropy,
so making sure your heart squeezes better
and chronotropy, making your heart go faster.
And then there's Beta-2, what does that do?
Actually does vasodilation, too.
So this one can actually make your blood pressure go down,
so I want you too keep that in mind as we go through this.
There's some different medications,
that affect some other receptors
and we'll talk a little bit about them,
when we hit those specific ones.
But these are sort of the key places to start.
All right.
The first medication I wanna start with is Phenylephrine.
Phenylephrine has mainly, like all,
Alpha-1 activity.
This is gonna squeeze your vessels,
but it's not gonna do a lot of good,
as far as making your heart beat faster or harder, okay?
So if you already have a heart problem,
this can be sort of a dangerous medicine to you,
'cause now your heart has to work even harder,
to overcome the squeezing of your blood vessels, okay?
So keep that in mind, all right?
The next one we're gonna talk about is Norepinephrine.
So this has a lot of alpha,
but also now we're bringing in the beta,
so you're getting some squeeze out of this, too.
And then we talk about Epinephrine
and we sort of are shifting across the screen,
as we do this.
So now we still have alpha, but we also have
a bunch of beta happening here, okay?
So this is strongly alpha and strongly beta.
And then we have Dobutamine.
So this is the first one, that we're gonna think of.
These all we think of as vasopressors.
Dobutamine we think of as an inotrope.
Really, what this is gonna do,
is make that heart squeeze faster and better.
So really that's gonna be way more over here.
All right (coughing in audience muffles voice)
ones, that are important for you to know.
So the first one is Vasopressin.
Vasopressin is its own deal,
it acts on a vasopressin receptor, okay?
And then the other one that we talk about is Dopamine.
I'm not gonna talk about Dopamine a lot,
because the thing about Dopamine is,
it causes more heart arrhythmias without really having
any benefit over some of the other agents.
Okay, so that's all we're gonna say
about Dopamine for today,
just don't worry about it so much.
Any questions about that so far?
Yeah.
- [Man] What about Milrinone?
- Oh, that's a great question.
So, Milrinone works by a different mechanism,
it's a phosphodiesterase inhibitor,
but it does exactly have the same effect on the end organs,
as Dopamine, Dobutamine, excuse me.
So I generally think of them together.
Okay, cool?
All right.
So now I wanna go through and talk about,
when we're gonna use these different medications
and I'm trying to leave a bunch of space
for my Norepinephrine,
'cause that's really gonna be our got to in most cases.
All right, so Epinephrine,
Dobutamine and Vasopressin.
Okay.
So Phenylephrine.
The main times we use Phenylephrine is,
we use it when we just need
some more squeeze in our blood vessels.
So a time, when we might wanna reach for that,
might be neurogenic shock.
A good time to use that is when we have someone,
who's in septic shock, but their heart rate
is already going really fast,
so we don't want their heart rate to go even faster.
So someone with septic shock an a fibric RVR,
it would be a good choice for them, okay?
But it's not really, first line first line for anything.
Okay?
We generally think of it as being nice to use,
because people are more comfortable using it,
through a peripheral IV,
but as we'll talk about,
we can also use some of these other ones,
through a peripheral IV temporarily,
while we get ourselves going too, okay?
But something to think about,
it can be good for neurogenic shock
and it can be good for septic,
or a fibric RVR.
All right, norepinephrine.
So norepinephrine is like first line, first line.
So it's first line for sepsis, for septic shock.
It's gonna be first line really for neurogenic,
and then I think of it as first line for cardiogenic,
if my blood pressure's really low, okay?
And we'll talk about why that is in just a second, okay?
With me so far?
Okay.
So that's our key times for norepinephrine.
Again, you're not really ever gonna be wrong,
going with norepinephrine as your first drug,
except for in one case,
which is the first one we'll talk about with epinephrine,
which is anaphylactic shock.
So this is absolute first line for anaphylactic shock
and then also for code situations,
it's really gonna be first line.
This is now second line,
for sepsis, for septic shock.
I'll talk more about what that means
and how that comes into the picture in a second, okay?
So Dobutamine, when would we use Dobutamine?
- [Woman] Cardiogenic shock.
- Yeah, perfect.
So cardiogenic shock is gonna be first line,
but the trick of it is that we talked
about how these beta receptors
can actually make your blood pressure go down, right?
So if we already have someone who's
in cardiogenic shock, with low blood pressure,
we have to make sure we get that up first,
'cause the Dobutamine will make
the blood pressure go lower first,
before that cardiac outlet really starts kicking in, okay?
So this is gonna be first line for cardiogenic,
if we have adequate blood pressure.
Yeah?
- [Woman] Will you have people on two,
like norepinephrine and Dobutamine?
- Yeah, great question.
So for our cardiogenic shock specifically
you're asking, yes.
So, you can have someone on that norepinephrine,
get their blood pressure to a safe place,
the try to get that Dobutamine started
and then try to get the norepi off
as you get that Dobutamine kicking in.
Okay, great question.
All right, vasopressin.
Vasopressin is gonna be second line,
for septic shock,
and, like I said, we're not gonna really talk Dopamine.
All right, so when I say that norepinephrine
is first line and epinephrine and vasopressin
are second line,
this is how I manage this situation.
If I have someone who is in septic shock
and I start them on norepinephrine,
so generally when I start someone on norepinephrine,
I start them at 10 micrograms per minute
and the reason I do that
is I want to that medicine to start getting
through that IV tubing and get into my patient
and then we generally think of the dose of this,
being anywhere from really,
like five to 30 micrograms per minute, okay?
So I get it into their body.
I try to take it down to five if I can.
I titrate it higher if I have to.
If I get to the point where I'm
on 15 micrograms per minute of norepinephrine,
then I go ahead tack on vasopressin.
Yeah?
- [Woman] If someone doesn't yet have a central line
and they only have a peripheral line,
is there a max dose of norepinephrine,
that they can have going through the peripheral line?
- So how I want you to keep thinking about this,
is you can use that peripheral line
as long as you have to.
If you have to give someone pressers,
through a peripheral line to keep them alive,
till you get them to a safe place
where they can safely get a line,
do that.
You wanna get a central line for these people
as fast as possible,
but if you have to give it through the peripheral line,
that's okay, okay?
I don't want you to not use it,
because you're afraid of some limit.
Give it to keep them alive,
get your central line as soon as you can.
Okay, cool.
All right, so again, we get this up to 15,
we add on our vasopressin.
So vasopressin dosing is different,
to then all the other medications.
So vasopressin, we think of the dose as
being .03 units per minute,
and we don't titrate that.
I just wanna think of vasopressin,
as hormone replacement.
So we just stick it on,
if we get to meeting 15 of norepinephrine,
we stick that on and we sorta let it hang out
and then we can stop it later as we need to, okay?
But we don't really titrate up and down,
like we sort of constantly titrate
up and down a lot of the others.
All right, cool.
So, the other option,
that some other folks will do,
is that once they're at that 15 of norepinephrine,
they may tack on the epinephrine.
That is a reasonable plan as well, okay?
And in general when we're talking,
about septic shock dosing,
the dose for this is also gonna be
for that five to 30 micrograms per minute.
Again, that 30 is an arbitrary limit,
because if you need more than that,
to keep someone alive,
you need more than that to keep someone alive, okay.
And then, as far as as septic shock is concerned,
we said that this is first line.
These two are second line.
Phenylephrine they say now is for special situations,
and like we talked about the special situation
would be someone who has septic shock
but their heart rate is already going super fast.
All right and then we think about
putting the Dobutamine if someone gets septic shock
and then starts getting some cardiac disfunction from that,
then we put this on to increase that squeeze.
This may be really key in our patients,
with Coronavirus, because our patients
with Coronavirus are often getting septic shock first
and then developing a cardiogenic shock after.
That's why I really wanna make sure we talked,
about all vasoactive meds, instead of just pressers.
Okay, so a couple other key points
I want you guys to take from this,
so Phenylephrine dosing is, usually,
I think about it as about zero to 200 micrograms per minute.
Sort of the dose there.
Pretty wide range of what you can use.
We don't really use it that much anymore
and then Dobutamine, we generally think of this dosing,
as being somewhere from
five to 20 micrograms per kilogram per minute.
The d-drugs tend to be microgram per kilogram per minute,
whereas the other ones tend to be microgram per minute.
Sort of easy way to remember that off-hand.
Yeah?
- [Woman] Just to remember again,
we're titrating these for a MAP greater than 65?
- Yep.
- [Woman] How are we measuring that?
Is it-
- That's a good question.
Okay, so a lot of places you can't setup an A-line
and have that ready to go with all the monitoring,
you need to make that happen and the tubing and whatnot.
So while, again, you're getting these medications going,
it's okay to use just your blood pressure cuff,
as your indicator for blood pressure,
until you get your patient to an intensive care unit,
where they can get that A-line in,
get that monitor going, okay?
So don't not use them because you can't get an A-line.
Get them started, save the life, then get the A-line.
Yeah?
- [Man] Is there anything else I should be looking at,
besides the blood pressure?
- That's a great question.
So the other thing that we wanna watch regularly,
is lactate.
So we watch lactate,
because lactate's an indication,
of well your body's perfusing
and that's the whole goal of this,
is to my sure we're perfusing our organs.
So you can do your lactate about every four hours
and see how you're treading lactate.
Hopefully that's clearing as you're managing the patient.
- [Woman] What is your cutoff to say,
that something is not well perfusing, for your lactate?
- That's a great question.
So really we use two as like our normal level.
So we really say at four someone's in shock.
Two is really where we wanna get people below.
Cool?
All right, so one more thing I wanna make a point of,
for you is epinephrine.
There's a lot of confusion about how to dose epinephrine
and we talked about this is the dose,
if we have someone on an epinephrine drip,
for septic shock, okay?
That's not the same as what we would give,
in these other two situations, which you have here, right?
So for our code situation,
we always go into the code cart
and we find our little auto-injector, bristojet,
whatever you wanna call it
and what does that have in it?
Anyone know?
So that has one milligram.
That has one milligram of IV epinephrine in it.
So we give that whole thing,
if we're doing ACLS on someone who has coded,
we give a milligram of epinephrine.
Anyone know what we give for anaphylactic shock?
- [Woman] Higher doses?
- Okay, so it's actually a lower dose
and we're gonna give it differently.
So if you think about an EpiPen,
that people take with them,
so the dose there,
so I'm gonna put here EpiPen
is .3 milligrams IM, okay?
So less and it's going IM not IV.
Okay, so that's a big point for you guys to remember.
We don't wanna just be pushing this
in someone who has anaphylactic shock.
We wanna be giving them EpiPen dosing.
If by chance you can't,
because you don't have anymore EpiPens,
then your plan is gonna be,
put them on a drip if you need to
or if you have to give them an IV dose,
it's actually 50 micrograms, is the dose of that,
which is a teeny-tiny fraction of that one milligram.
So key things that I want you to take from all of this,
is you can give them through a peripheral IV,
if you need to.
Norepi's a great place to start,
for almost all problems, okay?
But in this specific problem of Coronavirus,
consider that you're gonna have to
treat that septic shock first
and then probably come back
and do some treatment for that cardiogenic shock, okay,
and then get your A-line as soon as you can,
to really closely, every second,
monitor that blood pressure,
instead of having that blood pressure cuff
going really, really frequently.
Okay.
Yeah and then just also get your central line
as soon as you can.
Any other questions you guys have about that?
Okay, go forth and conquer.
Thanks guys.