ICU and Pressors

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Coastie

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So, in the midst of intern year, the MICU (even with 100 hour work weeks) is a bright light amongst ward months. Never thought I'd like it so much.

Anyway, can anyone give an overview of pressors and when best to use them in the ICU setting?

Also, any good references for reading up on CCM? I'm loving taking care of the really sick people and the load of procedures I'm getting, but I'd like to supplement all that work with reading to increase the knowledge. Thanks...
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Coastie said:
So, in the midst of intern year, the MICU (even with 100 hour work weeks) is a bright light amongst ward months. Never thought I'd like it so much.

Anyway, can anyone give an overview of pressors and when best to use them in the ICU setting?

Also, any good references for reading up on CCM? I'm loving taking care of the really sick people and the load of procedures I'm getting, but I'd like to supplement all that work with reading to increase the knowledge. Thanks...
Click to expand...

Grab any anesthesia text and check it out.

For now grab Marino's text and check pressors out there.

You basic pressors are:
Neosynephrine: pure alpha ------->reflex brady. Drop in CO. Gut and Renal killer because of the clamp effect.

DA----> starting dose 5ucg/kg/min BETA effect. As you approach 10 then you get more and more Alpha. Over 10 and you should switch drugs. DA bad because it causes lots of arrythmias. However still recomended as First Line for sepsis next to Levophed.

Levophed (norepinephrine)-------> Big bad daddy of vasopressors. Alpha>Beta. Limited Beta-2 means even more clamp down time. The beta tries to kick the CO up, but cardiac depression can occur if lacking adequate Preload/Inotropic support. If your patient aint tanked up right watch out for gut and peripheral LIMB ischemia. The bomb for septic shock.

Vasopressin------->yer standard .04ucg/min for shock. Great adjunct to any of the above. Antidiuretic and direct vasopressor effects (V1 and V2 receptors). Also commonly used for Sepsis.

Take home points: Pressors buy you time. But not infinite time. Find out the cause of your hypotension. Usually a form of shock. REVIEW SHOCK before using pressors.

Pressors KILL PATIENTS if they aren't adequately volume resuscitated by WORSENING ischemia.
 
what about ephedrine? in the OR it is pressor of choice...why is it not used in icu setting?
 
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because of catecholamine depletion? just yesterday my attending told me this didn't happen unless pts were on maoi's etc. but that didn't make sense to me...
 
amyl said:
what about ephedrine? in the OR it is pressor of choice...why is it not used in icu setting?
Click to expand...

Because its a wuss drug.

Epi is fine but its my last line of defense in a non-anyphalactic picture in someone with presumed/documented "normal" ventricular function. I usually side epi on the Inotropics but its a powerful pressor as well. Extremely dangerous in the wrong hands.

MAOI's will not deplete catechol. What can happen is an EXAGGERATED response to ephedrine. In the setting of MAOI's you're much better off using a direct agent (i.e. not Dopamine or Ephedrine).
 
Coastie said:
So, in the midst of intern year, the MICU (even with 100 hour work weeks) is a bright light amongst ward months. Never thought I'd like it so much.

Anyway, can anyone give an overview of pressors and when best to use them in the ICU setting?

Also, any good references for reading up on CCM? I'm loving taking care of the really sick people and the load of procedures I'm getting, but I'd like to supplement all that work with reading to increase the knowledge. Thanks...
Click to expand...

The best book/source BY FAR for pressors/ionotropes (and also take a look at the heparin/coagulation stuff in the book) is Hensley's cardiac anesthesia book. I can't think of the name but maybe VenTy can remember. Most anesthesia residents after their cardiac rotation will have it. It is a relatively small book, red cover. It is concise and goes over ever pressor you will need or want to use, mechanism of action, duration etc. Then, read the 1 or two pages on heparin/protamine/coagulation pathway, etc.
 
epidural man said:
The best book/source BY FAR for pressors/ionotropes (and also take a look at the heparin/coagulation stuff in the book) is Hensley's cardiac anesthesia book. I can't think of the name but maybe VenTy can remember. Most anesthesia residents after their cardiac rotation will have it. It is a relatively small book, red cover. It is concise and goes over ever pressor you will need or want to use, mechanism of action, duration etc. Then, read the 1 or two pages on heparin/protamine/coagulation pathway, etc.
Click to expand...


Hensley's: A practical approach to cardiac anesthesia. New edition out. Great book.
 
fakin' the funk said:
Does anyone else find it odd/inappropriate to call an endogenous catecholamine and obviously crucial neurotransmitter by its TRADE NAME?!
Click to expand...

In some ways, it actually helps clarify what you're talking about. If you say "Levophed," you are clearly referring to artifically produced, exogenously administered norepinephrine circulating in the blood in much higher levels than one would find under normal physiologic conditions.
 
Can anybody give me insight as to why multiple pressors / combinations of pressors are used on the post-op CT patients, and when to use which pressor combinations.

I'm a med student, and although its easy to read about what each pressor does, it is harder to understand how they are used in combination.

Thanks for any info or basic run down,
studyinghard
 
studyinghard said:
Can anybody give me insight as to why multiple pressors / combinations of pressors are used on the post-op CT patients, and when to use which pressor combinations.

I'm a med student, and although its easy to read about what each pressor does, it is harder to understand how they are used in combination.

Thanks for any info or basic run down,
studyinghard
Click to expand...

First, you need to change your status.

Second, this is a subject that is FAR too vast to discuss succinctly here. Suffice it to say that you should learn the difference between pressors (which act on the vasculature), inotropes (which increase the force of contraction of the heart), and chronotropes (which increase the speed of the heart).

There are drugs that do a combination of these, only one of these, or antagonize these. They are used in various combinations in specific situations, such as vasopressin (a pressor) and milrinone (an inotrope) given a particular clinical situation (well-resuscitated sepsis with concomitant cor pulmonale), and can be argued to death about what the appropriate monitoring devices in place should be, what the best combinations are, and what the treatment endpoints should be.

Know those differences: inotropes, chronotropes, pressors. Make a list, including where they overlap, and you'll be better at understanding the choices (e.g., epinephrine, for example, is all three). In fact, I'm sure if you ask Dr. Google someone's already done this for you.

-copro
 
studyinghard said:
Can anybody give me insight as to why multiple pressors / combinations of pressors are used on the post-op CT patients, and when to use which pressor combinations.

I'm a med student, and although its easy to read about what each pressor does, it is harder to understand how they are used in combination.
Click to expand...

Like copro said, it's hella complex. In 2 different patients the same drug and dose may produce different effects because of that patient's instrinsic physiology/pathophysiology and their preexisting hemodynamic state, e.g. preload, SVR, effective circulating volume, oxygen delivery, etc etc. You learn a gestalt and you learn what drugs/doses tend to work for which patients/populations and titrate to your desired effect. Over time this turns into, "At Institution X we use drugs A and B on postop CT surg patients" when there could be any number of correct approaches.

In med school it's easy to say "Ah, at low doses dopamine has a dopaminergic effect, at moderate doses primarily beta-1, and at higher doses alpha-1" because that's what's taught in books and that's what you study. In clinical practice things are much more fuzzy and you have to rely on your knowledge of drugs' properties and how they might apply to this particular patient, and go from there.
 
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