# Dopamine in Sepsis?



## CWATT (May 13, 2017)

According to the video below, the Surviving Sepsis Campaign protocols cite hypotensive management    priority as Norepinepherine, Vasopressin, then Epinepherine, and Dopamine ONLY indicated in patients at low risk of tachydysrhymias.  They also cite doBUTamine as possibly exacerbating hypotension.

However, I have protocols in two jurisdictions that cite Dopamine as the vasopressor for hypotension associated with sepsis.

I'm just wondering if anyone has any insight on what might be contributing to this discrepancy.  Are the protocols in my jurisdictions antiquated?  Also, why would a b1 agonist exacerbate hypotension?  Especially when combined with a vasopressor.

Vasopressors @ 4:00mins






- C


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## Handsome Robb (May 13, 2017)

We use levophed and epi, don't even carry dopamine anymore. 

Dobutamine would be a very poor choice for a septic person as it is an inotrope but also causes mild vasodilation which is the exact problem in septic shock. 


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## Carlos Danger (May 13, 2017)

CWATT said:


> According to the video below, the Surviving Sepsis Campaign protocols cite hypotensive management    priority as Norepinepherine, Vasopressin, then Epinepherine, and Dopamine ONLY indicated in patients at low risk of tachydysrhymias.  They also cite doBUTamine as possibly exacerbating hypotension.
> 
> However, I have protocols in two jurisdictions that cite Dopamine as the vasopressor for hypotension associated with sepsis.
> 
> I'm just wondering if anyone has any insight on what might be contributing to this discrepancy.  Are the protocols in my jurisdictions antiquated?  Also, why would a b1 agonist exacerbate hypotension?  Especially when combined with a vasopressor.



I don't think there is a lot of strong evidence for one vasopressor over another. That said, norepi has enjoyed a resurgence recently while dopamine has fallen out of favor for most applications. surviving sepsis guidelines are largely consensus-based and every recommendation is not necessarily the result of clear evidence. Personally I think norepi is easier to use. Dopamine is a "dirty" drug and cause cause significant tachycardia and dysrhythmias, along with other side effects.

Dobutamine would be fine in combination with a vasopressor. That was not an uncommon regimen before norepi became popular again.


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## StCEMT (May 13, 2017)

Is the inotropic effect of dobutamine beneficial in sepsis assuming you have an appropriately dosed vasopressor to help maintain bp? Or is that more of just a nice extra if you do have it?


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## Carlos Danger (May 13, 2017)

StCEMT said:


> Is the inotropic effect of dobutamine beneficial in sepsis assuming you have an appropriately dosed vasopressor to help maintain bp? Or is that more of just a nice extra if you do have it?



I can't think of any reason to use dobutamine + a vasopressor over norepi or dopamine. 

When you used to see it done I think it was probably because the dopamine had caused too much tachycardia, or they wanted to avoid tachycardia in the first place. And for a couple decades almost no one used norepi because it just had a really bad rap.


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## StCEMT (May 13, 2017)

What's the general in hospital opinion on having someone come in with an epi drip? I never had a moment come up to start a drip once I switched over to the tech spot and fortunately I now have norepi among my meds, but it was something I kept preset mixing calculations on since I went to nursing homes A LOT.

At least what bit I remember on the pressor A vs pressor B argument, epi isn't too bad of a choice and it's not like we have trouble scrounging some up for a simple drip. Maybe in @CWATT's case, this is an alternative worth asking about if the need ever arises.


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## Carlos Danger (May 13, 2017)

The problem with epi is it is pretty tough on the heart. At lower doses the beta effects predominate, and you can get some mild peripheral vasodilation. You have to give higher doses in order for alpha effects to predominate and get the desired pressor effect. All this adds up to a lot of increased cardiac work. Coronary vasodilation may not increase supply enough to meet the demand, especially at high heart rates. 

Norepi is the opposite: alpha effects predominate and beta effects are more proportionate to the increased afterload. You generally get less tachycardia. Less likely to cause an imbalance between myocardial oxygen supply and demand.

Either one can cause end-organ ischemia at high doses.


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## E tank (May 13, 2017)

NE is better in sepsis than dopamine. 30 day in hospital mortality is less....or something. Can't remember. It can be googled for the interested.

(caveat emptor....better when used with appropriate volume resuscitation.)


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## StCEMT (May 13, 2017)

Hmm, ok makes sense, thanks for breaking that down a bit more. I've read some of the articles on the options, but they don't really give the why that you did as much as simply comparing the end results.


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## Carlos Danger (May 14, 2017)

E tank said:


> NE is better in sepsis than dopamine. 30 day in hospital mortality is less....or something. Can't remember. It can be googled for the interested.



I think that is correct. They've been saying that for a while. But IIRC the evidence supporting this statement isn't all that robust. I've been wrong before though.


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## VFlutter (May 14, 2017)

StCEMT said:


> Is the inotropic effect of dobutamine beneficial in sepsis assuming you have an appropriately dosed vasopressor to help maintain bp? Or is that more of just a nice extra if you do have it?



Most patients with sepsis are hyper dynamic due to nonexistent afterload and high sympathetic tone. Later stages in sepsis when patients become profoundly acidotic with cardiac dysfunction it may have a place however at that point it may not be very effective.


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## NPO (May 14, 2017)

I talked to a former paramedic of ours who now works at our county LEMSA. I specifically talked to him about dopamine in sepsis because they are developing a sepsis protocol. Currently the only way our protocol includes dopamine for sepsis is reading between the lines in our Shock/Hypotension protocol, which is actually in our trauma protocol section, but doesn't specify anything about trauma in the protocol itself. 

I asked him the same question OP brought up. He has been in EMS longer than I've been alive, and what he told me is that Levophed used to be in the scope of practice, but that it gained negative conotation because many patients with the drug had poor outcomes, but in retrospect that's likely due to the patients getting the med were very sick. The term "Levophed or leave em dead" didn't help.

He agreed that moving back to levo in favor of dopamine would be good, and have an added benefit of continuity of care since it's what the hospitals are using. But he admitted it's unlikely anytime soon.

Shame. They say trauma and heart disease are leading causes of death in the prehospital setting.

I wonder how many patients are killed by dogma. 

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## Carlos Danger (May 14, 2017)

NPO said:


> I talked to a former paramedic of ours who now works at our county LEMSA. I specifically talked to him about dopamine in sepsis because they are developing a sepsis protocol. Currently the only way our protocol includes dopamine for sepsis is reading between the lines in our Shock/Hypotension protocol, which is actually in our trauma protocol section, but doesn't specify anything about trauma in the protocol itself.
> 
> I asked him the same question OP brought up. He has been in EMS longer than I've been alive, and what he told me is that Levophed used to be in the scope of practice, but that it gained negative conotation because many patients with the drug had poor outcomes, but in retrospect that's likely due to the patients getting the med were very sick. The term "Levophed or leave em dead" didn't help.
> 
> ...


I don't like dogma either, but really I doubt any patients are going to be killed by EMS using dopamine in the field for sepsis instead of levo. Like I said before, I don't think the evidence supporting levo over dopamine is great, but even if it is, using dopamine for transport and then the intensivists in the ICU switching to whatever they think is most appropriate is probably not going to cause harm.


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## NPO (May 14, 2017)

Remi said:


> I don't like dogma either, but really I doubt any patients are going to be killed by EMS using dopamine in the field for sepsis instead of levo. Like I said before, I don't think the evidence supporting levo over dopamine is great, but even if it is, using dopamine for transport and then the intensivists in the ICU switching to whatever they think is most appropriate is probably not going to cause harm.


I'm not specifically referring to dopamine vs levo, but EMS's (at least in my state) unwillingness to adapt to changes and improvements in care. 

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## FLMedic311 (May 14, 2017)

Remi said:


> I don't like dogma either, but really I doubt any patients are going to be killed by EMS using dopamine in the field for sepsis instead of levo. Like I said before, I don't think the evidence supporting levo over dopamine is great, but even if it is, using dopamine for transport and then the intensivists in the ICU switching to whatever they think is most appropriate is probably not going to cause harm.



 I am sorry to say but this is not an accurate statement.  Dopamine through plenty of studies has been shown to be associated with an increased mortality.  The Surviving Sepsis Campaign being a valid one in and of itself.  I do not believe that any single person on this forum is educated or experienced enough to speak against the recommendations of a committee of MD's whose sole commitment has been to research, test, and study the treatment of sepsis.  Your statements are dogmatic..


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## VFlutter (May 14, 2017)

FLMedic311 said:


> I am sorry to say but this is not an accurate statement.  Dopamine through plenty of studies has been shown to be associated with an increased mortality.  The Surviving Sepsis Campaign being a valid one in and of itself.  I do not believe that any single person on this forum is educated or experienced enough to speak against the recommendations of a committee of MD's whose sole commitment has been to research, test, and study the treatment of sepsis.  Your statements are dogmatic..



I think Remi was talking about short term prehospital use as opposed to prolonged use in the ICU which is what surviving sepsis is really talking about. I agree that using Dopamine vs Levophed to initially stabilize a patient for an hour until they get to the ER/ICU is not an issue.


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## FLMedic311 (May 14, 2017)

I can appreciate what you're saying about the difference in short vs long term use.  Reading through all the post it does not seem that way and my concern is that it comes off as saying using Dopamine is not a big deal, when in fact it is.. If you have a pt dying of sepsis about to arrest and you have no other pressor available and you grab dopamine, ok..  But the matter of the fact is you had a better option, Epi, and everyone has it.  Even short term use in high enough doses will increase urine output potentially causing worsening hypovolemia.


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## FLMedic311 (May 14, 2017)

I will say @Remi  I apologize, when reading my initial post my words come off harsh off my tongue and I am not trying to incite conflict as much as conversation and consideration.  Having read a number of your posts I know you are not only intelligent but well intended in your comments


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## Carlos Danger (May 14, 2017)

FLMedic311 said:


> I am sorry to say but this is not an accurate statement.  Dopamine through plenty of studies has been shown to be associated with an increased mortality.  The Surviving Sepsis Campaign being a valid one in and of itself.  I do not believe that any single person on this forum is educated or experienced enough to speak against the recommendations of a committee of MD's whose sole commitment has been to research, test, and study the treatment of sepsis.  Your statements are dogmatic..



Well first, I did not "speak against" any recommendations. Never did I say that the surviving sepsis guidelines were wrong or that they shouldn't be followed. I simply said that _to my understanding_, the strength of the data supporting norepi over dopamine was not overwhelming. I even wrote "but I've been wrong before" to indicate that I wasn't 100% sure about that. I read the 2016 guidelines when they came out and I'm pretty familiar with them, but as someone who doesn't manage patients in the unit, I don't make it a big priority to stay up-to-the minute on all the nitty gritty details.

Then after you called me out here, I went back and reviewed the section of the guidelines that discusses vasopressors. Turned out I was right after all. On page 19 of the guidelines, under Section G, "Vasoactive Medications", the very first line says "We recommend norepinephrine as the first choice vasopressor (strong recommendation, moderate quality of evidence). I briefly looked at the meta analysis that this recommendation is based on, and without getting to far into the weeds discussing the studies in the meta-analysis, suffice it to say that it's pretty clear why the authors of the study describe the quality of evidence as "moderate" rather than "high". Don't confuse quantity of evidence with quality of evidence.

Second, the guidelines themselves are not evidence. They are a consensus document formed from the *opinions* of a group of clinicians from various backgrounds (most of whom are NOT researchers themselves, as you claim), many of which may not even agree all that strongly with certain parts of the final recommendations. I happen to think the Surviving Sepsis guidelines are pretty solid (I think all of the SCCM's recommendations are about as good as they come), but don't forget that it was "the experts" who used to tell us that high-dose epi was good for cardiac arrests, that backboards should be used on all trauma patients, that bleeding patients should receive enough IVF to raise their BP to a near normal level, that everyone should get high-flow oxygen, and that 10-15 ml/kg was a good tidal volume. We could go on and on with stuff that "experts" have been wrong about.

Lastly, I doubt that there is any evidence at all that the choice of vasopressor in the prehospital phase affects eventual outcomes, certainly not large, high-quality studies. Unless that data does in fact exist, you can't make the claim that using dopamine prehospital for sepsis has any impact.



FLMedic311 said:


> Your statements are dogmatic..


Skepticism is actually the opposite of dogma. Don't blindly accept everything that you read or are told. Look it up and evaluate the the validity and importance for yourself. Be a clinician, not a drone.


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## FLMedic311 (May 14, 2017)

Remi said:


> Skepticism is actually the opposite of dogma. Don't blindly accept everything that you read or are told. Look it up and evaluate the the validity and importance for yourself. Be a clinician, not a drone.



 I have no problem with Constructive Skepticism, I do believe that the phenomena of sepsis like all forms of resuscitation has a long ways to go and we may never know the true answer to what is actually best practice.  However, when you doubt something only for the sake of suspicion, that is destructive.  The only way we progress forward from guidelines with moderate quality of evidence is better research.  In the meantime, the best we have is simply that and there is plenty of evidence to suggest that Dopamine has increased mortality compared to both Epi and NE.  



Remi said:


> I doubt any patients are going to be killed by EMS using dopamine in the field for sepsis instead of levo.



Just to clarify, this is the only thing I was referring to.  All of your prior statements to this one I agree with 100%.  Based on your response it appears as though you felt like I was referencing everything you have said, and that is not what I intended.  I simply meant this one statement


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## Alan L Serve (May 15, 2017)

Epi will bring up the pressure but it decreases cerebral blood flow. Pick your poison- low BP or low brain.


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## VFlutter (May 15, 2017)

Alan L Serve said:


> Epi will bring up the pressure but it decreases cerebral blood flow. Pick your poison- low BP or low brain.



Epi causing reduced cerebral blood flow during CPR in pigs should not deter you from using it as a vasopressor in shock. Significant hypotension can cause watershed infarcts just as easily in critically ill patients.


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## MackTheKnife (May 15, 2017)

Remi said:


> I can't think of any reason to use dobutamine + a vasopressor over norepi or dopamine.
> 
> When you used to see it done I think it was probably because the dopamine had caused too much tachycardia, or they wanted to avoid tachycardia in the first place. And for a couple decades almost no one used norepi because it just had a really bad rap.


Levophed- Leave 'Em Dead. 

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## Summit (May 15, 2017)

This is the norepi vs dopamnine metanalysis published in CCM in 2012
https://www.ncbi.nlm.nih.gov/pubmed/22036860



> *METHODS AND MAIN RESULTS:*
> We retrieved five observational (1,360 patients) and six randomized (1,408 patients) trials, totaling 2,768 patients (1,474 who received norepinephrine and 1,294 who received dopamine). In observational studies, among which there was significant heterogeneity (p < .001), there was no difference in mortality (relative risk, 1.09; confidence interval, 0.84-1.41; p = .72). A sensitivity analysis identified one trial as being responsible for the heterogeneity; after exclusion of that trial, no heterogeneity was observed and dopamine administration was associated with an increased risk of death (relative risk, 1.23; confidence interval, 1.05-1.43; p < .01). In randomized trials, for which no heterogeneity or publication bias was detected (p = .77), dopamine was associated with an increased risk of death (relative risk, 1.12; confidence interval, 1.01-1.20; p = .035). In the two trials that reported arrhythmias, these were more frequent with dopamine than with norepinephrine (relative risk, 2.34; confidence interval, 1.46-3.77; p = .001).




For peds, epi vs dopamine this prospect db rct showed a marked increased in mortality for use of dopamine. Treating with dopamine vs epi, number needed to harm was 8.
https://www.ncbi.nlm.nih.gov/pubmed/26323041

You can msg me if your institution doesn't have access.


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## Summit (May 15, 2017)

I guess my thought is that depending on what we think underlies the difference in mortality. Studies had mean exposure time to vasopressors of 2 days.

Authors from the metastudy note:
"Fifth, the time of exposure in a randomized fashion to dopamine or norepinephrine was limited to a few hours in some of the randomized trials (25, 29, 30), and there was no mention of which vasopressor agent was used thereafter in these patients (patients may have received the alternate drug later on in their course). Any exposure to dopamine or norepinephrine may influence outcome and incorporating trials with short exposures in the analysis may limit the chance to disclose differences between the agents. Nevertheless, limiting the analysis to the three trials that ensured maximal exposure to trial drugs provided similar results"

So if I consider RR of 1.12 for the dopa or norepi or OR 6.7 for dopa and epi, I start thinking that the 1-2 hours of EMS vasopressor treatment would make an outsized difference relative to the still significant portion of the treatment time, particularly managing the sicker patient that is getting an EMS vasopressor treatment where it seems necessary in the field. Now that is speculation on my part... but it is speculation based on the evidence.

Both norepi and dopamine are both reasonable short term peripheral pressors... so... (and if they are sick enough to need a vasopressor, IO them)


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## medicsb (May 24, 2017)

I think dopamine and epi are adequate as far as pressers for EMS.  Dopamine may not be necessary since push dose epi would be fine in an urban or dense suburban setting.  Dopamine is far far more likely to expire than be used on a patient  Having work for an ALS service that cover 2 counties with a combined population of 900,000, we used dopamine maybe 3 times a year and those were usually post-arrest patients.  When it comes to sepsis, most clinicians (myself included) prefer to get a couple liters in to the patient before initiating pressers.  I can't think of a time where I initiated a pressor on a patient within the first 30 minutes of care other than in the post cardiac arrest patient (in those cases, I typically use epi). Actually, I don't think I've done it within an hour.


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## truetiger (May 31, 2017)

Why would dopamine and epi be adequate for EMS? Why not levo? Why not use the proper drug? Why would you give a presumably tachycardic patient dopamine? I always hear the argument, well we only use drug x so many times a year. But what about those times we needed that drug? I think we owe it to our communities to stock the drugs needed to do the job and be competent on their use. Any service with extended transport times should be prepared to encounter any and all disease processes.


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## TXmed (May 31, 2017)

truetiger said:


> Why would dopamine and epi be adequate for EMS? Why not levo? Why not use the proper drug? Why would you give a presumably tachycardic patient dopamine? I always hear the argument, well we only use drug x so many times a year. But what about those times we needed that drug? I think we owe it to our communities to stock the drugs needed to do the job and be competent on their use. Any service with extended transport times should be prepared to encounter any and all disease processes.



I understand what youre saying, and i dont necessarily disagree.

But, epi is in my opinion a very versatile drug when used properly. And all of these medications are dangerous when used improperly. So i would much rather have a group of medics very familiar and knowledgable with epi (or dopamine or levo). Than kinda familiar with 3 pressors+ 2 inotropes+ etc. And whether paramedics care to admit it or not, you will NOT be profeciant with these meds if you only use them once every 3-4years.


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## truetiger (May 31, 2017)

I don't think it would be asking too much to be proficient in 3 vasopressors. I can't see administering EPI to a tachycardic patient turning out well.


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## Summit (May 31, 2017)

truetiger said:


> I don't think it would be asking too much to be proficient in 3 vasopressors. I can't see administering EPI to a tachycardic patient turning out well.


Uh... huh?


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## TXmed (May 31, 2017)

They do it for sepsis patients


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## truetiger (May 31, 2017)

Do what for septic patients?


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## TXmed (May 31, 2017)

Epinephrine for sepsis patient. And generally they are tachy.


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## truetiger (May 31, 2017)

Levo should be first line in sepsis....


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## TXmed (May 31, 2017)

That doesnt mean its not some peoples first line. And that doesnt mean its not given to a patient whos still tachy. Some people respond better to epi than the levo. Some people like vaso as 2nd line. 

Point being you can use alot of these meds to accomplish the same task. Its just knowing how to use them to get the outcome you desire.


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## truetiger (May 31, 2017)

But the thing is...it shouldn't be your first line.


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## TXmed (May 31, 2017)

Well its first line in my hospital for cold sepsis.


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## FLMedic311 (Jun 1, 2017)

TXmed said:


> Well its first line in my hospital for cold sepsis.


I don't mean this to be a sarcastic question, but why? Has anybody stated a reason for this protocol I am curious! Thanks!


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## TXmed (Jun 1, 2017)

Im still relatively new to this hospital/flight program. But from what ive been told and have seen. Most sever septic patients are catacholamine depleted and replacing those is the initial step. Not everyone is norepi depleted, not everyone is epi depleted, sometimes its neither and alot of times its both. Long story ahort they think in cold sepsis you need epi first and they respond better. 

Its not a big deal anyways as theyre real big on stackong pressors so they rarely use jist epi or just levo. They would rather use both at 4mcg than one of them at  14mcg


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## FLMedic311 (Jun 1, 2017)

Interesting, and once again not accusing but on that theory are you guys carrying/using vasopressin?


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## Summit (Jun 1, 2017)

FLMedic311 said:


> Interesting, and once again not accusing but on that theory are you guys carrying/using vasopressin?


Yep... I haven't seen the septic shock patient where I have said, "I wish this patient was just on Epi!" instead of, "I'm glad to add Epi to my Norepi and Vaso!"

But I think truetigers hope of "comfortable with 3 pressors" thing is frikin pipedream. I'll bet far less less than 1% of medics need more than one hand to count the number of times they've used more than one pressor... or maybe even just one pressor!

That is the problem with "dabbling" in critical care, you don't get the experience needed to act intuitively. I know I feel a bit weaker right now doing vasoactives a few times a year than when I was titrating often multiple vasoactives hundreds of hours a year. When dealing with low frequency high risk interventions, it actually is the time to have fewer tools (and the RIGHT tools) with highly algorithmic approaches.


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## NPO (Jun 1, 2017)

It's funny, I just attended a sepsis lecture hosted by one of our hospitals' ICU medical director yesterday. 

He stressed fluids, then pressors. I asked him in the absence of Levo, what pressors to use and he told me epi, and not to wait very long if at all. I have up to a 1.5h transport to a decent hospital in my area, and he pretty much told me fluids in quick, and if no improvement move to epi quickly. He also stressed looking at MAP and pretty much disregarding SBP completely. 

He said he uses SvO2 and lactate to guide treatment of sepsis and admits that in that respect we are pretty much blind, but encouraged aggressive treatment anyway. 

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## Summit (Jun 1, 2017)

NPO said:


> It's funny, I just attended a sepsis lecture hosted by one of our hospitals' ICU medical director yesterday.
> 
> He stressed fluids, then pressors. I asked him in the absence of Levo, what pressors to use and he told me epi, and not to wait very long if at all. I have up to a 1.5h transport to a decent hospital in my area, and he pretty much told me fluids in quick, and if no improvement move to epi quickly. He also stressed looking at MAP and pretty much disregarding SBP completely.
> 
> Sent from my Pixel XL using Tapatalk


It's sound advice. Even short hypoperfusion shocks the kidneys. Fluid first, fluid fast, if it works then stops, use more, if not, press.

Nobody titrates shock patients to SBP in the ICU. MAP MAP MAP. In the ICU about the only order with SBP parameters is "titrate following drips to keep SBP BELOW" in a post-CABG or or other vascular pt or a neuro. But we do tend to have a-lines...


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## VentMonkey (Jun 1, 2017)

@NPO ground or air shifts, I have gotten in the habit of adding the MAP to my base reports, particularly if I feel the hospitals feelers may, or should be up.

My random non-thread related tidbit.


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## NPO (Jun 1, 2017)

VentMonkey said:


> @NPO ground or air shifts, I have gotten in the habit of adding the MAP to my base reports, particularly if I feel the hospitals feelers may, or should be up.
> 
> My random non-thread related tidbit.


I am going to do the same, where it may be pertinent to the patients condition. 

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## VFlutter (Jun 1, 2017)

FLMedic311 said:


> I don't mean this to be a sarcastic question, but why? Has anybody stated a reason for this protocol I am curious! Thanks!



I would assume the added inotropic support from epi when septic patients go from hyperdynamic to "stunned" and acidotic. 

Although no catecholamines work well in an acidotic patient IRRC Epi is the most effective in extreme pHs


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## Summit (Jun 1, 2017)

Chase said:


> IRRC Epi is the most effective in extreme pHs



Would love to read that paper


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## VFlutter (Jun 1, 2017)

Summit said:


> Would love to read that paper



Actually the only one I found shows the Levo performed equal if not slightly better then Epi. I will try to find the actual paper I am thinking of.


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## Carlos Danger (Jun 1, 2017)

truetiger said:


> Why would dopamine and epi be adequate for EMS? Why not levo? Why not use the proper drug? Why would you give a presumably tachycardic patient dopamine? I always hear the argument, well we only use drug x so many times a year. *But what about those times we needed that drug?* I think we owe it to our communities to stock the drugs needed to do the job and be competent on their use. Any service with extended transport times should be prepared to encounter any and all disease processes.



But that is just it......you don't NEED a drug that you only use a couple of times a year when you already carry another drug that produces similar effects.

As we discussed already in this thread, the evidence supporting the recommendations for the use of levo vs. other pressors in sepsis is not overwhelmingly strong. It was only described as "moderate" quality by the authors of the sepsis recommendations. For all we know the smartest doctors on the panel that was tasked with writing that part of the recommendations didn't even agree that norepi should be first-line, but all the rest did. I'm not suggesting that's the case, I'm just saying......consensus guidelines are based on what is essentially a democratic process, and we all know how well those work sometimes.

The point is, while I think the Surviving Sepsis guidelines are probably solid recommendations, they aren't based on such great evidence that it is irresponsible to do something a little different, especially outside the ICU environment, where you can't expect to have all the same resources and expertise.

Show me a high-quality study that indicates that septic patients have worse outcomes when something other than norepinephrine is used during prehospital transport, and I'll agree with you that norepi should be stocked on every ALS using with longer than, say, 20 minute transport times. Until that time, you have no basis for such a strong opinion on the issue, and I'll continue to believe that it is better for people who rarely use pressors and rarely manage critical patients to keep their protocols simple and stick to the drugs that they are most familiar with.


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## VFlutter (Jun 1, 2017)

Remi said:


> But that is just it......you don't NEED a drug that you only use a couple of times a year when you already carry another drug that produces similar effects.



Unfortunately we have gotten rid of Vasopressin due to infrequency of use and high cost but in all fairness there are not many situations where I could not get it from the referring facility before leaving. But I am sure there will be a time I will desperately want it and not have it.


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## FLMedic311 (Jun 1, 2017)

I would like to add that while I completely agree that there is not enough evidence to say that Levo is the hands down best first line pressor.  I disagree that Dopamine is an acceptable first line for any service.  There is more then enough evidence to support that there is an increased mortality with the use of Dopamine and given every truck in the nation at the very least has access to Epi.


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## Summit (Jun 1, 2017)

FLMedic311 said:


> I would like to add that while I completely agree that there is not enough evidence to say that Levo is the hands down best first line pressor.  I disagree that Dopamine is an acceptable first line for any service.  There is more then enough evidence to support that there is an increased mortality with the use of Dopamine and given every truck in the nation at the very least has access to Epi.


I concur


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## RocketMedic (Jun 2, 2017)

I'm a supporter of levophed and epinepherine. If I recall correctly, one of the greatest drawbacks of dopamine in sepsis is that it relies on the body to release catecholamines to actually function, and in the septic patient, the body is depleting its stockpile of readily-available catecholamines to the point where dopamine simply won't provoke further catecholamine release. In my opinion, there hunting is better in the land of -epi.


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## E tank (Jun 2, 2017)

RocketMedic said:


> I'm a supporter of levophed and epinepherine. If I recall correctly, one of the greatest drawbacks of dopamine in sepsis is that it relies on the body to release catecholamines to actually function, and in the septic patient, the body is depleting its stockpile of readily-available catecholamines to the point where dopamine simply won't provoke further catecholamine release. In my opinion, there hunting is better in the land of -epi.



You might be thinking of ephedrine. Very similar effect as dopamine but acts indirectly, increasing endogenous catechols activity on SNS receptors. You're correct in that this drug requires that the patient not be depleted of endogenous catecholamines. Heavy methamphetamine use can do this as well as different shock states. 

But dopamine is a direct acting alpha and beta agonist, so there is no concern there.


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