septic shock AND massive M.I.

[Painter1]

60-year-old White male hx of cancer s/p chemotherapy becomes pancytopenic with consequent e. coli bacteremia and distributive shock. intubated for airway protection after episode of tachypnea. unresponsive to fluids, blood pressure responds to dopamine, later switched to neo and levo. subsequent labs reveal trop of 6 and ckmb of 50.

is MI an uncommon complication of distributive shock? did the pressors contribute or cause the M.I.?

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[Painter1]

he was hovering consistently around 85/50 before we went down to transfer him to the ICU. when we cycled his blood pressure once there he was 68/37. at that point the dopamine drip was started. i never saw his bp more than 120/60 since. this are all rough values.

 

[Eidolon6]

NSTEMI is not an uncommon complication of septic shock, esp in at risk patients with preexisting coronary disease. In general as a low flow state through at risk coronary circulation may lead to ischemia and infarction. Its likely the addition of pressors with his level of blood pressure were more likely to help coronary perfusion than hurt it. Doses of dopamine and levophed employed in resuscitation of distributive shock oft are not adequate to cause frank coronary vasospasm.

Diffuse myocardial injury in septic shock is well reported and reduction of LVEF in throes of sepsis have as well. This injury may or may not manifest as a troponin leak and often a function study is needed to assess cardiac function.

Also, know what chemo he got might be helpful, as for example anthracyclines like adriamycin are toxic to the myocardium.

All those being said....an echo would be helpful to assess his cardiac function. In the absence of that, a PA catheter could be employed....if his cardiac output is not appropriate in the setting of distributive shock, you are likely dealing with multifactorial (cardiac and septic shock)....and the ride will be bumpy....Inotropes may need to be employed.

 

[Painter1]

NSTEMI is not an uncommon complication of septic shock, esp in at risk patients with preexisting coronary disease. In general as a low flow state through at risk coronary circulation may lead to ischemia and infarction. Its likely the addition of pressors with his level of blood pressure were more likely to help coronary perfusion than hurt it. Doses of dopamine and levophed employed in resuscitation of distributive shock oft are not adequate to cause frank coronary vasospasm.

Diffuse myocardial injury in septic shock is well reported and reduction of LVEF in throes of sepsis have as well. This injury may or may not manifest as a troponin leak and often a function study is needed to assess cardiac function.

Also, know what chemo he got might be helpful, as for example anthracyclines like adriamycin are toxic to the myocardiu
All those being said....an echo would be helpful to assess his cardiac function. In the absence of that, a PA catheter could be employed....if his cardiac output is not appropriate in the setting of distributive shock, you are likely dealing with multifactorial (cardiac and septic shock)....and the ride will be bumpy....Inotropes may need to be employed.

awesome, thanx for posting your resonse. i didn't even think about the chemo connection. to be honest, i don't know what chemo he received. i'm not directly caring for the patient. i'm the lowly scutted-out intern in the team.

care to school me on pressors (e.g. dop, neo, and levo) and which ones to use and when?

 

[Pose]

Why is this posted in three or more forums?

 

[Painter1]

Why is this posted in three or more forums?

first, i value the input from anesthesiologists, emergency medicine docs, and intensivists. secondly, the discussion in each of the three forums creates a learning point for those that may exclusively frequent that particular forum.

 

[militarymd]

awesome, thanx for posting your resonse. i didn't even think about the chemo connection. to be honest, i don't know what chemo he received. i'm not directly caring for the patient. i'm the lowly scutted-out intern in the team.

care to school me on pressors (e.g. dop, neo, and levo) and which ones to use and when?

Isn't that whay your attending is supposed to do?

SCCM has a nice set of practice parameters for them along with the references behind the rationale for choosing which when.

 

[Painter1]

Isn't that whay your attending is supposed to do?
.

it's my first week and running around and buried in scut I had unfortunately not been able to sit down and research and read for myself and there hadn't been downtime to ask why which pressor was started versus another etc etc.

Thanks for the reference, but from your reply and viewing the anesthesiolog forum for a while now, why are you so judgemental and angry all the time?

 

[Qtip96]

it's my first week and running around and buried in scut I had unfortunately not been able to sit down and research and read for myself and there hadn't been downtime to ask why which pressor was started versus another etc etc.

Thanks for the reference, but from your reply and viewing the anesthesiolog forum for a while now, why are you so judgemental and angry all the time?

chill out my frenetic and ignorant friend.

it is against sdn policy to double post (no less triple post), and most people will feel as though you are wasting their time. consider your audience and choose carefully. your inconsiderate argument can be used by anyone, resulting in this board's being flooded with useless banter and repetition of advice.

further, militarymd is far more experienced than you, and you should heed his advice. his discussions, though blunt and sometimes argumentative, are most of the time sincere, informative, and seldom rude.

further, if you had time to post on 3 message boards, read their responses and submit written replys (to a bunch of strangers no less), you SHOULD HAVE SPENT YOUR VALUABLE TIME READING APPROPRIATE TEXTS AND REFERENCES.

massive MI... what a crock.

 

[2ndyear]

care to school me on pressors (e.g. dop, neo, and levo) and which ones to use and when?[/QUOTE]

Here's the quick and dirty. What do you want to squeeze? If you mainly need an increase in SVR you need alpha. Neo, Levophed.
Need to squeeze the heart, you need beta. Dobutamine for pure beta. Get a little with Levo but alpha effects predominate.
You'll have to read about Dopamine. A little bit of everything.

 

[militarymd]

Thanks for the reference, but from your reply and viewing the anesthesiolog forum for a while now, why are you so judgemental and angry all the time?

The reference is the standard of care....Should be something you read during your ICU rotation.....ie....I'm saying you should read it to figure what which pressor to use....not ask anonymous people on the internet....I could tell you that methylene blue is the best pressor out there...and you wouldn't know if it was true or not....

However, the SCCM practice parameters is something that no one will dispute.

As for being "judgemental"....yes I am....but I am NOT angry.


and BTW...methylene blue is really a great pressor in the severely septic patient....tell that to your attending and impress the crap out of him.

 

[Qtip96]

and BTW...methylene blue is really a great pressor in the severely septic patient....tell that to your attending and impress the crap out of him.

methylene blue... a potent inhibitor of guanylate cyclase and nitric oxide synthase. we use it to reverse hypotensive vasoplegia associated with NO therapy. i've never used it for septic shock however... care to elaborate??

 

[militarymd]

methylene blue... a potent inhibitor of guanylate cyclase and nitric oxide synthase. we use it to reverse hypotensive vasoplegia associated with NO therapy. i've never used it for septic shock however... care to elaborate??

I've only used it a handful of time to reverse critical hypotension from sepsis...(nitro oxide scavenging effect)...however, all of the patients expired.....

It bought time for family to be present....so in the grand scheme of things...not something helpful in treating surviveable sepsis....

 

[Qtip96]

I've only used it a handful of time to reverse critical hypotension from sepsis...(nitro oxide scavenging effect)...however, all of the patients expired.....

It bought time for family to be present....so in the grand scheme of things...not something helpful in treating surviveable sepsis....

pretty cool. i'll read up on it. thanks!

 

[Painter1]

chill out my frenetic and ignorant friend.

it is against sdn policy to double post (no less triple post), and most people will feel as though you are wasting their time. consider your audience and choose carefully. your inconsiderate argument can be used by anyone, resulting in this board's being flooded with useless banter and repetition of advice.

further, militarymd is far more experienced than you, and you should heed his advice. his discussions, though blunt and sometimes argumentative, are most of the time sincere, informative, and seldom rude.

further, if you had time to post on 3 message boards, read their responses and submit written replys (to a bunch of strangers no less), you SHOULD HAVE SPENT YOUR VALUABLE TIME READING APPROPRIATE TEXTS AND REFERENCES.

massive MI... what a crock.

i'm a nerd so i read the crap out of topics. and this is one topic i'll be shorty relatively well versed in. however, it's different reading texts than to hear real life experiences (e.g. as we just saw, mil just gave us a nice piece of methylene blue). i'm not an idiot so if i'm not gonna take everything posted hear as hard facts.

secondly, you strike me as someone who isn't smart. so refrain from addressing me.

 

[militarymd]

i'm a nerd so i read the crap out of topics. and this is one topic i'll be shorty relatively well versed in. however, it's different reading texts than to hear real life experiences (e.g. as we just saw, mil just gave us a nice piece of methylene blue). i'm not an idiot so if i'm not gonna take everything posted hear as hard facts.

secondly, you strike me as someone who isn't smart. so refrain from addressing me.

 

[2ndyear]

Methylene Blue has also been used to help with the 'vasoplegic' effect of ACE inhibited patients on bypass, at least it has at Brown. I'd be interested in trying it on other sick patients who have been on ACEi up until surgery. As far as I'm aware, the literature has no real consensus on whether these drugs should be continued like beta blockers perioperatively. I've read both pro and con studies. Thoughts?

 

[Qtip96]

Methylene Blue has also been used to help with the 'vasoplegic' effect of ACE inhibited patients on bypass, at least it has at Brown. I'd be interested in trying it on other sick patients who have been on ACEi up until surgery. As far as I'm aware, the literature has no real consensus on whether these drugs should be continued like beta blockers perioperatively. I've read both pro and con studies. Thoughts?

when refering to ACEi, i would be more inclined to describe it as a pharmacologic "vasodilator" effect, and reserve the description "vasoplegia" for a physiologic state.

there is a clear benefit for peri-operative beta-blockers. and likely statins in high risk athero patients (like vascular surg. populations). whether to use peri-op ACEi depends on it's purpose. if it is for HTN, it usually isn't necesary, because general anesthesia will usually drop BP and vasodilate. as for the CABG population, a lot of these patients are on milrinone and epi post-op, and i can't imagine the additional benefit of using ACEi until they are ready to transition to PO agents. further, there are plenty of IV agents that are more readily titratable in the peri-op setting than using ACEi. you might consider continuing a stable ACEi dose when used for CHF.

i haven't seen methylene blue used clinically very often. in all my years (including liberal use of NTG in cardiology fellowship), i have never encountered a case of methemoglobinemia. pity too, 'cause i have always wanted to blot a little blood on a filter paper to look like a star. i have principally seen methylene blue used for refractory hypotension in the setting of inhaled nitric oxide therapy (for pulm HTN and elevated PA pressures after cardiac surgery). this use makes sense because of the mechanism of action of methylene blue, and it actually works! considering NO therapy costs $500/hr, it is used very sparingly however, and this clinical scenario is uncommon.

 

[Annette]

. . .i have never encountered a case of methemoglobinemia. pity too, 'cause i have always wanted to blot a little blood on a filter paper to look like a star. . . .

Not to change the subject, but how do you get filter paper in your hospital, or do you have a personal supply? I had to once explain to the lab why they had to send me a guiac card instead of me sending the poop down to them. I offered to demonstrate why on the tech personally.

 

[Qtip96]

Not to change the subject, but how do you get filter paper in your hospital, or do you have a personal supply? I had to once explain to the lab why they had to send me a guiac card instead of me sending the poop down to them. I offered to demonstrate why on the tech personally.

yeah, no Whatman around either. the premise is to spread out the blood to aerate it (exposing it to oxygen). a standard white paper towel should do...

 

[2ndyear]

$500/hr for NO...I've heard Dr. Zapol has a few great houses on the Cape thanks to NO. Now I see why.