2 ionodilators sepis

[Sonny Crocket]

Anesthesiologist here.

Recently intubated a patient with sepsis who was on both simdax and dobutamine. There was an ICU doc in charge (not me). Seemed weird to me that the patient was on two ionodilators plus adrenalin infusion. He was extremely sick and died shortly after I left. Anyone here have experience with this? I understand the need for iontropy but wouldn't one ionodilator plus noradrenaline make more sense?

The history was anotherwise 'healthy' 67 year old. BMI 32 I would say. Most likely influensa. No invasive monitoring (Picco, swan ganz) at the time.

Thanks

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[jdh71]

Anesthesiologist here.

Recently intubated a patient with sepsis who was on both simdax and dobutamine. There was an ICU doc in charge (not me). Seemed weird to me that the patient was on two ionodilators plus adrenalin infusion. He was extremely sick and died shortly after I left. Anyone here have experience with this? I understand the need for iontropy but wouldn't one ionodilator plus noradrenaline make more sense?

The history was anotherwise 'healthy' 67 year old. BMI 32 I would say. Most likely influensa. No invasive monitoring (Picco, swan ganz) at the time.

Thanks

There are two different mechanisms involved between the simdax and dobutamine so maybe he was hopping for some synergy. It's probably a situation where it's not right or wrong. The patient sounds like they were crumping hard and fast. Sometimes you toss everything you can think at it. But without knowing the doc's thought process who knows why he did what he did. Perhaps the heart looked wimpy on his bedside echo?

 

[lymphocyte]

Anesthesiologist here.

Recently intubated a patient with sepsis who was on both simdax and dobutamine. There was an ICU doc in charge (not me). Seemed weird to me that the patient was on two ionodilators plus adrenalin infusion. He was extremely sick and died shortly after I left. Anyone here have experience with this? I understand the need for iontropy but wouldn't one ionodilator plus noradrenaline make more sense?

The history was anotherwise 'healthy' 67 year old. BMI 32 I would say. Most likely influensa. No invasive monitoring (Picco, swan ganz) at the time.

Thanks

The underlying pathophysiology matters a lot, as does the dose (different dose, different drug) but adrenaline and dobutamine makes no sense to me. Noradrenaline + dobutamine or adrenaline, but the combination lets you fine tune ionotropy and vasomotor tone more precisely and is probably less arrhythmogenic than adrenaline alone (though equivocal in septic shock). Decent evidence for trialing levosimendan and titrating a vasopressor or another ionotrop as needed.

Levy B, Perez P, Perny J, et al: Comparison of norepinephrine–dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenics shock A prospective, randomized pilots study Crit Care Med 2011; 39:450 – 455

Annane et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 676-84.

Delle Karth G, Buberl A, Geppert A, et al:
Hemodynamic effects of a continuous infusion of levosimendan in critically ill patients with cardiogenic shock requiring catecholamines. Acta Anaesthesiol Scand 2003;47:1251–1256

 

[Instatewaiter]

The underlying pathophysiology matters a lot, as does the dose (different dose, different drug) but adrenaline and dobutamine makes no sense to me. Noradrenaline + dobutamine or adrenaline, but the combination lets you fine tune ionotropy and vasomotor tone more precisely and is probably less arrhythmogenic than adrenaline alone (though equivocal in septic shock). Decent evidence for trialing levosimendan and titrating a vasopressor or another ionotrop as needed.

Levy B, Perez P, Perny J, et al: Comparison of norepinephrine–dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenics shock A prospective, randomized pilots study Crit Care Med 2011; 39:450 – 455

Annane et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 676-84.

Delle Karth G, Buberl A, Geppert A, et al:
Hemodynamic effects of a continuous infusion of levosimendan in critically ill patients with cardiogenic shock requiring catecholamines. Acta Anaesthesiol Scand 2003;47:1251–1256

I would argue Norepi + dobutamine doesn't make a whole lot of sense either. You are basically performing pharacologic warfare pitting an inodilator vs a predominant vasoconstrictor with a bit of inotropy. Why not nitroprusside + vasopressin?

 

[jdh71]

I would argue Norepi + dobutamine doesn't make a whole lot of sense either. You are basically performing pharacologic warfare pitting an inodilator vs a predominant vasoconstrictor with a bit of inotropy. Why not nitroprusside + vasopressin?

In septic shock?

 

[Instatewaiter]

NTP + vasopressin was a joke. Pure vasodilator + pure vasopressor is just ridiculous.

 

[leviathan]

I would argue Norepi + dobutamine doesn't make a whole lot of sense either. You are basically performing pharacologic warfare pitting an inodilator vs a predominant vasoconstrictor with a bit of inotropy. Why not nitroprusside + vasopressin?

As someone else mentioned, norepi is used for SVR. Dobutamine is then used for inotropy. While some of the vascular tone from levo might be counteracted by dob, you can then just go up on the levo as necessary. A slightly different approach might be to give vaso and dobutamine. Or vaso and epi, assuming you use lower dose epi.

 

[SurfingDoctor]

Yeah, but did he get hydrocortisone...