When Ephedrine and Neo don't work,

[Noyac]

---

Members don't see this ad.

What's your go to drug of choice?

Mine is small dose epi (10mcg).

Anyone, using vasopressin?

 

[militarymd]

yes on the vasopressin 2.5 unit boluses....not as effective or predicteable as you may think..

I've used methylene blue before..works well

but epi most frequentlyu.

 

[Tenesma]

call the CRNA to come in and take over the case... they have all the answers.

 

[jetproppilot]

What's your go to drug of choice?

Mine is small dose epi (10mcg).

Anyone, using vasopressin?

Me too.

 

[huktonfonix]

yup, epi is my back up with doubling up as needed, 10, 20, 40, 80, uh oh.....

 

[coprolalia]

Is 10mcg of epi really a "small" dose?

-copro

 

[powermd]

10 mikes of epi tells the patient firmly, and in no uncertain terms

STOP TRYING TO DIE.

I like the prolonged action of a unit or two of vasopressin, but onset isn't as fast as epi, or as predictable. For portal vein unclamping epi, calcium, and bicarb are my drugs of choice.

 

[amyl]

10 mikes of epi tells the patient firmly, and in no uncertain terms

STOP TRYING TO DIE.

QUOTE]

🙂 👍

 

[cchoukal]

We seem to use a lot of vaso here, in 1 unit boluses, but I have to admit, 10-20 mcg epi is pretty fail-safe. Anyone have any input on the supposed splanchnic protective effects of vaso? I've heard, anecdotally, both that it's MORE and LESS active in these beds than in other parts of the body...

 

[amyl]

splanchnic protective effects maybe compared to epi which vasoconstricts splanchnics

 

[cchoukal]

splanchnic protective effects maybe compared to epi which vasoconstricts splanchnics

Well, right; that's what I'm getting at, but does anyone have any papers/experience on this?

 

[drccw]

I am a vaso fan in 1-2 unit boluses if I have refractory hypotension....
It seems to work well for those ACE inhibited patients...

If i feel like they are really unstable then epi is what I reach fo...

 

[DrDre']

we use "peds epi" , 10 mcg/ml. This is always drawn up and in the room.

I am a vaso fan in 1-2 unit boluses if I have refractory hypotension....
It seems to work well for those ACE inhibited patients...

If i feel like they are really unstable then epi is what I reach fo...

 

[deleted50478]

steroids too, if indicated.

 

[Mman]

2 units of vasopressin seems to work like 100-200 mcg of phenylephrine, but for about 15-20 minutes instead of 2-4 minutes. I use it mostly on patients that are on multiple HTN meds preop including ACE-Is and respond to anesthesia by losing their SVR in a big way.

 

[PMPMD]

Well, right; that's what I'm getting at, but does anyone have any papers/experience on this?

YES. (papers, not experience)


Woolsey CA and Coopersmith CM. Vasoactive drugs and the gut: is there anything new? Curr Opin Crit Care 2006; 12:155–159.

This is a nice review of the subject. Both vaso and epi cause splanchnic vasoconstriction (specifically in septic shock). Unclear whether this generalizes to all patients receiving vaso.

some of the more salient references from the above review:

Westphal M, Freise H, Kehrel BE, et al. Arginine vasopressin compromises gut mucosal microcirculation in septic rats. Crit Care Med 2004; 32:194–200. "While many studies have been done assessing the effect of vasopressin on mucosal blood flow and tonometry, this excellent manuscript looks at videomicroscopy in a rat model of septic shock."

Martikainen TJ, Uusaro A, Tenhunen JJ, Ruokonen E. Dobutamine compensates deleterious hemodynamic and metabolic effects of vasopressin in the splanchnic region in endotoxin shock. Acta Anaesthesiol Scand 2004;48:935–943. "This study compared vasopressin to vasopressin combined with dobutamine in a porcine model of shock. Vasopressin had adverse effects on splanchnic metabolism, while the addition of dobutamine prevented these deleterious effects."

Martikainen TJ, Tenhunen JJ, Giovannini I, et al. Epinephrine induces tissue perfusion deficit in porcine endotoxin shock: evaluation by regional CO(2) content gradients and lactate-to-pyruvate ratios. Am J Physiol Gastrointest Liver Physiol 2005; 288:G586–G592. "This well done study compared splanchnic tissue perfusion in pigs given epinephrine or norepinephrine. A number of complex measurements led the authors to conclude that there is a substantial perfusion deficiency of the gastric wall in epinephrine not seen when giving norepinephrine."


Voelckel, WG, et al. Effects of vasopressin and epinephrine on splanchnic blood flow and renal function during and after cardiopulmonary resuscitation in pigs. Crit Care Med 2000; 28(4):1083-1088

This study compared the effects of vaso and epi on the splanchnic circulation in a porcine model and found that vaso caused MORE splanchnic vasoconstriction than epi. "In the early postresuscitation phase, superior mesenteric blood flow was temporarily impaired by vasopressin in comparison with epinephrine."


Whereas this study found no difference in splanchnic vasoconstriction between the 2 drugs:

Prengel AW, et al. Splanchnic and renal blood flow after cardiopulmonary resuscitation with epinephrine and vasopressin in pigs. Resuscitation 1998; 38(1):19-24. "In comparison to epinephrine, vasopressin given during cardiac arrest impairs renal and adrenal perfusion temporarily but does not lead to intestinal or hepatic hypoperfusion in the post-resuscitation phase."

Holmes CL and Walley KR. Vasopressin in the ICU. Curr Opin Crit Care 2004; 10:442–448.

A nice overall review of vasopressin. Again confirming the splanchnic vasocontricting effects of vaso (at least in septic shock).

"Vasopressin worsened gastrointestinal perfusion in two human studies and one animal study."

 

[dfk]

yes on the vasopressin 2.5 unit boluses....not as effective or predicteable as you may think..

I've used methylene blue before..works well

but epi most frequentlyu.

hey mil,
do you use a specific dose of this, or the entire amp?

 

[militarymd]

hey mil,
do you use a specific dose of this, or the entire amp?

5 to 10 mg.....no more than 0.5 mg/kg....why? I don't know.