Pressors.

[joeDO2]

I think this is a great discussion, for the most part.

It has highlighted the lack of evidence for pressor choice.

However, I remain a dopamine hater (no GOOD evidence to support this, I admit).

Based on experience, anecdote, or theory, can anyone describe a situation when dopamine - the most promiscuous, destabilizing, and unknown of pressors - is their first choice?

JDH? You above implied it's indicated in specific situations. Can you provide an example?

And, yes: I know the AHA likes it - but the AHA likes all kinds of nonsense and my opinion of ACLS has been expressed elsewhere. Without citing the AHA, can anyone explain why they think dopa is a good idea for the unstable bradycardia patient? ....vs epi, pacing, correcting the underlying etiology?

HH

my personal opinion would be correcting underlying etiology > pacing > epi > dopa
(if those are the 4 choices)

I can really only see a few unusual cases where someone might pick dopa first.
1. you are in an environment with limited resources where pacing or proper sedation for pacing is not immediately available. although i favor pacing, i'm not aware of any evidence showing mortality benefit over a pressor therefore it would be difficult to make a guideline against its use (if anyone is aware of a study please let me know).
2. I know a lot of the prehospital folks like dopa because it is fairly easily hand-titratable and you can adjust the effects by playing with the dose depending if you want inotropy/HR control or vasoconstriction. much easier to change drip rate than changing pressors / adding pressors when you are 1 person managing the patient. dopamine comes in a premixed bag so it makes things easier/quicker (but not better). mixing up an epi infusion takes some extra time.

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[pinipig523]

my personal opinion would be correcting underlying etiology > pacing > epi > dopa
(if those are the 4 choices)

I can really only see a few unusual cases where someone might pick dopa first.
1. you are in an environment with limited resources where pacing or proper sedation for pacing is not immediately available. although i favor pacing, i'm not aware of any evidence showing mortality benefit over a pressor therefore it would be difficult to make a guideline against its use (if anyone is aware of a study please let me know).
2. I know a lot of the prehospital folks like dopa because it is fairly easily hand-titratable and you can adjust the effects by playing with the dose depending if you want inotropy/HR control or vasoconstriction. much easier to change drip rate than changing pressors / adding pressors when you are 1 person managing the patient. dopamine comes in a premixed bag so it makes things easier/quicker (but not better). mixing up an epi infusion takes some extra time.

Pacing? Never seen it used for shock states other than those sx brady +/- low lying heart blocks. I have no idea where this idea comes from.

For me, pressor choice is as follows:

1. Dopamine to start, if all I have is peripheral line and if they are volume depleted.
2. If HR too high, then levophed or phenylephrine.
3. If cardiogenic shock (hypotensive decompensated CHF), I used dopamine (for afterload maintenance) and dobutamine (for relief of pulmonary hypertension).

 

[joeDO2]

Pacing? Never seen it used for shock states other than those sx brady +/- low lying heart blocks. I have no idea where this idea comes from.

For me, pressor choice is as follows:

1. Dopamine to start, if all I have is peripheral line and if they are volume depleted.
2. If HR too high, then levophed or phenylephrine.
3. If cardiogenic shock (hypotensive decompensated CHF), I used dopamine (for afterload maintenance) and dobutamine (for relief of pulmonary hypertension).

sorry should have been more clear....was referring to use in symptomatic bradycardia only, not generally for shock states.

 

[TrustMe]

I also, have found very few uses for dopamine. The only one being bradycardia and hypotension together.

Levophed is great for shock and hypotension. If they don't respond to this very well initially I like to add a background of vasopressin in conjunction. If pt. has low cardiac output and hypotension I like epinephrine or levo/milrinone combination. Occasionally use dobutamine for shock pt's with low C.O. if I have a PAC (which I rarely do in these pt's).

I have had some great response with methylene blue for refractory hypotension and severe vasodilation. While not a true 'pressor' it prevents peripheral nitric oxide production, thus improving vascular tone and allowing other pressors to work more effectively. Had a liver transplant recently who was excessively hypotensive and vasodilated after reperfusion (on 0.3mcg/kg/min of levo, 2.4u/hr of vaso, C.O. of 16L/min and SVR<200). Gave a bolus of methylene blue (2mg/kg and ran infusion at 0.25mg/kg/hr for 6-8 hrs post-op (pt. was hepatorenal on HD so high-dose or extended infusions are not recommended)). Pt. was off pressors by the next morning. I like the blue stuff for severe, refractory, vasodilation.

 

[Hamhock]

I also, have found very few uses for dopamine. The only one being bradycardia and hypotension together.

Epi?

HH

 

[TrustMe]

Epi?

HH

Yes. I guess what I meant is that the only time I even consider dopamine is that scenario. And then I usually only ponder it for the amount of time it takes me to sit down and order epinephrine.

TM

 

[joeDO2]

thought i'd bump this thread after reading the article that was recently posted in emcrit

http://www.ncbi.nlm.nih.gov/pubmed/22036860

fairly convincing evidence to not use dopamine

 

[jdh71]

thought i'd bump this thread after reading the article that was recently posted in emcrit

http://www.ncbi.nlm.nih.gov/pubmed/22036860

fairly convincing evidence to not use dopamine

I think I just found my next journal club article - if someone doesn't beat me to it!!

 

[pseudoknot]

thought i'd bump this thread after reading the article that was recently posted in emcrit

http://www.ncbi.nlm.nih.gov/pubmed/22036860

fairly convincing evidence to not use dopamine

I am not sure that is "fairly convincing evidence." It's a pretty small effect and barely reached statistical significance, with a lot of manipulation needed to arrive at that conclusion. Yeah, dopamine might be a little bit worse than norepi but it's not like one of them is deadly poison and the other one is some sort of miracle potion. I think if there were a huge difference it probably would have been seen by now. I do prefer norepi but don't think it's worth going to the mat over, especially when you still have people using CVPs and such...

 

[RustedFox]

Bump for a good read.

 

[deleted109597]

I personally like the last line of pseudoknot's post.

 

[RustedFox]

Necrobump for this image file, from EmCrit's new "pressors" podcast. Lolz.

 

[engineeredout]

Can someone explain to me why phenylephrine is supposed to be safer in peripheral lines? I had always thought it was the alpha activity of pressures that caused the risk of ischemic injury.

 

[da8s0859q]

Pacing? Never seen it used for shock states other than those sx brady +/- low lying heart blocks. I have no idea where this idea comes from.

For me, pressor choice is as follows:

1. Dopamine to start, if all I have is peripheral line and if they are volume depleted.
2. If HR too high, then levophed or phenylephrine.
3. If cardiogenic shock (hypotensive decompensated CHF), I used dopamine (for afterload maintenance) and dobutamine (for relief of pulmonary hypertension).

Great necrobump. One question for anyone: in #2 above, how high would be too high for you?

Why I ask: was once called from prehospital setting with a presumed septic shock, HR 130-150 person, sinus tach. Difficult and delayed access. IO placed with fluids finally running some time after initial call, BP 70s systolic at best for awhile. Mentation in and out. Only had push-dose epi and dopamine for my choices for pressors outside the ED. Went with a stick of the former in case it came down to it, never had to use it. No phenylephrine available. Finally had a PIV and another liter hanging, slight improvement in vitals after awhile in a long transport, though still way hypotensive and still tachy. Made me wonder what others' comfort levels would be with using something with that kind of beta 1 activity out of necessity in such a setting in case of being even more behind the 8-ball than I started in that.

 

[turkeyjerky]

Can someone explain to me why phenylephrine is supposed to be safer in peripheral lines? I had always thought it was the alpha activity of pressures that caused the risk of ischemic injury.

Because phenylephrine isn't nearly as potent as the others

 

[shookwell]

I don't really have much to add to the discussion, but these articles that I've read recently came to mind while browsing this thread. The first is definitely recommended reading although it's specific to septic shock.

Early Management of Severe Sepsis:Concepts and Controversies
http://journal.publications.chestnet.org/article.aspx?articleid=1876092

Circulatory shock
http://www.nejm.org/doi/full/10.1056/NEJMra1208943

Comparison of Dopamine and Norepinephrine in the Treatment of Shock
http://www.nejm.org/doi/full/10.1056/NEJMoa0907118



I hear there is a large study about to be published showing that all pressors are safe in peripheral lines, but I don't know the details.

 

[TheDudeMD]

Because phenylephrine isn't nearly as potent as the others

By that logic it seems that when you finally titrate it up to therapeutic levels, then it would start sclerosing veins at the same rate.