Cardiogenic shock: Difference between revisions
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#Achieve MAP >65
#Achieve MAP >65


===Pressors===
{{Vasopressor table}}
 
{| class="wikitable"
|-
! Pressor!! Initial Dose !! Max Dose !! Cardiac Effect  !! BP Effect !! Arrhythmias !! Special Notes
|-
| Dobutamine || 2.5mcg/kg/min || 10-40 mcg/kg/min || mainly inotrope (ß1) || alpha effect minimal || Some HR(ß1) increase. Also Increase SA and AV node fx || Debut Research 1979<ref>Edmund H. Sonnenblick, M.D., William H. Frishman, M.D., and Thierry H. LeJemtel, M.D. Dobutamine: A New Synthetic Cardioactive Sympathetic Amine</ref> Isoproterenol has most Β2 vasodilatory and Β1 HR effects
|-
| Dopamine || 2mcg/kg/min || 20-50 mcg/kg/min || β1 and NorEpi release || α effects if > 20mcg/kg/min || Arrhythmogenic from β1 effects || More adverse events when used in shock compared to Norepi<ref name="soap2">De Backer Daniel et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM 363(9). 779-789</ref>
|-
| Norepinephrine || 8-12mcg/min || 30 mcg/min || β1 direct effect || β1 and α1,2 effects || Less arrhythmias than Dopamine<ref  name="soap2"></ref>  || Increases MAP, coronary perfusion pressure, little β2 effects.
|-
|Milrinone || 50mcg/kg x 10 min || 0.375-75mcg/kg/min || Direct influx of Ca<sup>2+</sup> channels|| Smooth muscle vasodilator ||  || PDE Inhibitor which increases Ca<sup>2+</sup> uptake by sarcolemma.  No venodilatory activity
|-
| Phenylephrine || 100-180mcg/min then 40-60mcg/min || 0.4-9 mcg/kg/min  ||  || Alpha agonist  ||  || Long half life
|-
| Vasopressin || Fixed Dose || 0.4 U/min || unknown || increases via ADH peptide ||  || should not be titrated due to ischemic effects
|}


===Other Therapies===
===Other Therapies===

Revision as of 07:22, 18 February 2015

Background

  • Leading cause of death in pts w/ MI who reach the hospital alive

Etiology

Clinical Presentation

Physical Exam

  • Assess for signs of CHF
    • elevated JVD, pulmonary edema, S3
  • Assess for valvular disease (MR, critical AS, or aortic regurgitation)
  • Assess e/o end-organ hypoperfusion
    • cool/mottled extremities, weak pulses, AMS, decreased UOP
  • Assess for pulsus paradoxus (cardiac tamponade)

Work-Up

  • Labs
    • Troponin
    • Lactate
    • CBC
    • Chem
    • BNP
      • <100 may rule-out cardiogenic shock
  • ECG
  • CXR
  • TTE

Differential Diagnosis

Shock

Treatment

  • General
    • Intubation
      • Decreases O2 demand BUT may worsen preload
  • Coronary perfusion
  1. Small Fluid challenge
  2. Increase inotropy
    1. Titrate to clinical effect
      • Dobutamine or Milrinone:
      1. Use milrinone if pt is on BB
      2. CaCl 1gm
        1. Give if pt is hypocalcemic
  3. Achieve MAP >65

Vasopressors

Pressor Initial Dose Max Dose Cardiac Effect BP Effect Arrhythmias Special Notes
Dobutamine 3-5 mcg/kg/min 5-15 mcg/kg/min (as high as 200) [1] Strong ß1 agonist +inotrope +chronotrope, Weak ß2 agonist +weak vasodilatation ) alpha effect minimal HR variable effects. indicated in decompensated systolic HF, Debut Research 1979[2] Isoproterenol has most Β2 vasodilatory and Β1 HR effects
Dopamine 2 mcg/kg/min 20-50 mcg/kg/min β1 and NorEpi release α effects if > 20mcg/kg/min Arrhythmogenic from β1 effects More adverse events when used in shock compared to Norepi[3]
Epinepherine 0.1-1 mcg/kg/min + inotropy, + chronotropy
Norepinephrine 0.2 mcg/kg/min 0.2-1.3 mcg/kg/min (5mcg/kg/min) [4] mild β1 direct effect β1 and strong α1,2 effects Less arrhythmias than Dopamine[3] First line for sepsis. Increases MAP with vasoconstriction, increases coronary perfusion pressure, little β2 effects.
Milrinone 50 mcg/kg x 10 min 0.375-75 mcg/kg/min Direct influx of Ca2+ channels Smooth muscle vasodilator PDE Inhibitor which increases Ca2+ uptake by sarcolemma. No venodilatory activity
Phenylephrine 100-180 mcg/min then 40-60 mcg/min 0.4-9 mcg/kg/min Alpha agonist Long half life
Vasopressin Fixed Dose 0.01 to 0.04 U/min unknown increases via ADH peptide should not be titrated due to ischemic effects
Methylene blue[5] IV bolus 2 mg/kg over 15 min 1-2 mg/kg/hour Possible increased inotropy, cardiac use of ATP Inhibits NO mediated peripheral vasodilation Don't use in G6PD deficiency, ARDS, pulmonary hypertension
Medication IV Dose (mcg/kg/min) Concentration
Norepinephrine (Levophed) 0.1-2 mcg/kg/min 8mg in 500mL D5W
Dopamine 2-20 mcg/kg/min 400mg in 250 D5W
Dobutamine 2-20 mcg/kg/min 250mg in 250 mg D5W
Epinephrine 0.1-1 mcg/kg/min 1mg in 250 D5W

Other Therapies

  • Transfusion
    • Consider if Hb < 10

Specific Situations

  1. Mitral Regurg
    1. Need to increase forward flow
    2. Dobutamine (contractility)
    3. Nitroprusside (afterload reduction)
  2. MI
    1. PCI or thrombolysis
  3. Aortic Stenosis
    1. Do not give preload reducers such as Nitro
    2. Patients are flow dependent over stenotic value. Flow proportional to degree of stenosis and afterload.
    3. Maintain flow by decreasing afterload (use with extreme caution and in very small carefuly titrated doses)
      1. Nitropruside
      2. Dobutamine
      3. Hydralazine
  4. Toxins
    1. Beta-Blocker Toxicity
    2. Calcium Channel Blocker
    3. Digoxin

See Also

Source

  1. ↑ https://www.ncbi.nlm.nih.gov/pubmed/8449087
  2. ↑ Edmund H. Sonnenblick, M.D., William H. Frishman, M.D., and Thierry H. LeJemtel, M.D. Dobutamine: A New Synthetic Cardioactive Sympathetic Amine
  3. ↑ 3.0 3.1 De Backer Daniel et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM 363(9). 779-789
  4. ↑ https://www.ncbi.nlm.nih.gov/pubmed/15542956
  5. ↑ Pasin L et al. Methylene blue as a vasopressor: a meta-analysis of randomised trials. Crit Care Resusc. 2013 Mar;15(1):42-8.
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