# Dope Vs. Epi Drip selection question



## TYMEDIC (Apr 21, 2012)

Hey all, need some insight here.
Besides the given indication for sepis, cardiogenic shock. When would you go epi over dopamine? Oviously refractory to fluid administration. I understand if patient's are catecholmine depleted from prolonged adrenergic stimulation, dopamine wont be effective. It just seems like practioners always say "you try dopamine, if that doesnt work, go to epi". 
I just need more information and clarification. Also, can someone give me insight with epi administration on cardio shock.... doesnt make sense, it could cause cardiotox levels to raise affecting myocardium, increase MVO2 as well. Thanks all!


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## Doczilla (Apr 21, 2012)

I can't remember ever seeing epi for cardiogenic shock--- maybe, i dunno. I will say though, if you can't access nor-epi, vasopressin (makes an excellent drip, done it with great results) dobutamine, or phenylephrine, and you don't want to use dopamine, best to slap the CPAP on and hawl bawls. Epi isn't even remotely ideal.


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## usalsfyre (Apr 21, 2012)

If norepi and neo are the "rifles" of pressors, dopamine the "shotgun", then epi is the nuclear warhead. Proceed with caution.


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## 18G (Apr 21, 2012)

Bradycardia refractory to pacing/atropine and severe anaphylaxis would be two cases for an epi drip.


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## the_negro_puppy (Apr 21, 2012)

Our Icps give epi/adrenaline for:

Bradycardia with poor perfusion unresponsive to atropine and or pacing
Shock (exuding haemorrhagic) unresponsive to fluid

We dont have infusion pumps so they give it 20/50mg at 1 minute intervals no max dose.

We dont carry dopamine here.


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## Farmer2DO (Apr 21, 2012)

Are you talking about 911 or IFT?  2 different worlds.  Even for 911, it's going to depend on your transport time.

I don't see much use for epi drips.  I've seen them used in critical asthmatics and in anaphylactic shock.  I've never seen them for cardiogenic shock.  Usalsfyre's comment about each agent is appropriate.  

I do see them when the patients come out of the OR post CABG; our cardiac surgeons seem to like it, using it for its inotropic effect.  Sure, its got pressor effect, with a ton of inotropic effect, causing a significant increase in myocardial oxygen demand.  I've seen some post arrests that seem to get pulses back every time you push epi, and then lose them, respond well to an epi drip.  Their long term prognosis usually isn't too hot.

I'm not a dopamine fan, either.  If you want a pressor, choose levo, vaso or neo.  Dopamine just causes so much cardiac irritability.  If you need an inotrope, remember that if the patient is ischemic at all, you will probably hasten their demise at the expense of increased cardiac output.  If they're not ischemic, and just have a big, weak, sloppy heart, then dobutamine is my first line.  If they fail that, milrinone.  If they fail milrinone, then they probably need a VAD and evaluation for a heart transplant.


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## Dwindlin (Apr 21, 2012)

Farmer2DO said:


> I'm not a dopamine fan, either.  If you want a pressor, choose levo, vaso or neo.  Dopamine just causes so much cardiac irritability.  If you need an inotrope, remember that if the patient is ischemic at all, you will probably hasten their demise at the expense of increased cardiac output.  If they're not ischemic, and just have a big, weak, sloppy heart, then dobutamine is my first line.  If they fail that, milrinone.  If they fail milrinone, then they probably need a VAD and evaluation for a heart transplant.



Would like to second this remark. My sentiments exactly.


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## kindofafireguy (Apr 21, 2012)

Recently ran a cardiogenic shock that they ended up hanging levophed for over everything else. We called a STEMI alert in route to the hospital but he never even made it to the cath lab. His pressure (even after 1.2L and levophed in the ER) never made it above 72/46. 

That was a bad one.


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## MSDeltaFlt (Apr 22, 2012)

You need to look at your drugs' stimulation and what kind of shock your pt is in.

Remember you have a1, a2, b1, b2, d1, & d2 stimulation. Dopamine and Dobutamine are dose specific.  Levophed is primarily a, but also has some b1. Where Neo is all a.  Now epi is primarily b1. Starting an epi on a cardiogenic shock pt you'll make a taxed heart run faster.  Pretty much shooting yourself in the foot. Need to weigh risk versus benefit here.  Epi drips on these pts are usually a last ditch effort.


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## Doczilla (Apr 22, 2012)

Has anyone messed with vasopressin drips?


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## TYMEDIC (Apr 22, 2012)

MSDeltaFlt said:


> You need to look at your drugs' stimulation and what kind of shock your pt is in.
> 
> Remember you have a1, a2, b1, b2, d1, & d2 stimulation. Dopamine and Dobutamine are dose specific.  Levophed is primarily a, but also has some b1. Where Neo is all a.  Now epi is primarily b1. Starting an epi on a cardiogenic shock pt you'll make a taxed heart run faster.  Pretty much shooting yourself in the foot. Need to weigh risk versus benefit here.  Epi drips on these pts are usually a last ditch effort.



What about with anaphlaxis and the bad shock patient's that are catacolemine depleted. When those specific patients have over stimulated the adrenergic nervious system, is that deem a last ditch effort? Should be around the beginning stages of decompensation.


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## usalsfyre (Apr 22, 2012)

TYMEDIC said:


> What about with anaphlaxis and the bad shock patient's that are catacolemine depleted. When those specific patients have over stimulated the adrenergic nervious system, is that deem a last ditch effort? Should be around the beginning stages of decompensation.


I can't say I've run into that many catecholamine depleted patients in the emergent setting to worry about it. These are really the late stage "cold" sepsis patients. How many of those do you see a year?

Going around looking for reasons to hang epi infusions is a good way to kill patients after making sure they lose a few digits.


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## MSDeltaFlt (Apr 23, 2012)

TYMEDIC said:


> What about with anaphlaxis and the bad shock patient's that are catacolemine depleted. When those specific patients have over stimulated the adrenergic nervious system, is that deem a last ditch effort? Should be around the beginning stages of decompensation.



Those "bad shock patients" you mentioned?  If that's when you see them, you're probably starting at the last ditch effort. Kinda need to see the big picture here... that and follow your protocols. What do they say to do?  What do they say you do NOT do?


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## Handsome Robb (Apr 23, 2012)

Doczilla said:


> Has anyone messed with vasopressin drips?



I helped a nurse managing a septic patient during my ICU rotations. We spent all day in that room, pt had Neo, levo and vasopressin drips running, cant recall the doses off the top of my head but I know 2 were "maxed" out and one was close to it. 

She was a sick pup though even with all of those her MAP wasn't much if any above 65. 

We actually swapped from a Dopamine drip to the Vasopressin then continued to add the Levo the eventually the Neo. Pt was taching away in the 150s on the dopamine with a crap pressure and frequent PVCs, as soon as we swapped to the vaso her heart slowed way down and the PVCs became much less frequent, pressure stayed about the same. 

Don't know if that answers your question.


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## Farmer2DO (Apr 23, 2012)

Doczilla said:


> Has anyone messed with vasopressin drips?



I use vaso quite a bit.  It's considered adjunctive, so anytime I have someone already on pressor therapy, and they're not right exactly where I want them, I add vaso.  I've had good luck with it.

I was taught to run it at 0.04 IU/minute.  No titration, no weaning.  Our CVICU will take it up to 0.4 IU/min.  I've seen that with ridiculous doses of levo and neo, like 0.2 mg/kg/min of levo and 10 mcg/kg/min of neo.  They call it Rocket Fuel.


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## Doczilla (Apr 23, 2012)

They found that vasopressin works better in sepsis anyway- because sepsis is associated with massive uncontrolled exertion of NO on the vasculature.... Vasopressin plays a role in blocking NO formation as well as vasoconstricting without the aid of the sympathetic nervous system.


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## Doczilla (Apr 23, 2012)

I've had great results with vasopressin. We had a guy come in who had been dying for a few days at the local hospital , after ingesting a large quantity of an unknown medication. For the short time he was still awake, he was screaming about how he as going deaf--- one of the hallmarks of salicylate toxicity. Stomach was hard as a rock. Pressure was around 60/40. 

Tried crystalloids,colloids,and even transfused his *** two times, with minimal effect on pressure. As a hail mary, i added 20 units of vasopressin to 500ml of NS and ran it at 1 ml/min (.04 units per min). Pressure was 104/70 20 mins later, and stayed that way until he made it to the local ANA hospital. 

Great stuff.


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## 18G (Apr 23, 2012)

usalsfyre said:


> Going around looking for reasons to hang epi infusions is a good way to kill patients after making sure they lose a few digits.



I've actually read something that makes really good sense concerning an epi drip for anaphylaxis. For older patients experiencing anaphylaxis, it was recommended that an epi drip be started and not SQ/IM. Reason being the epi drip is easily titrated and can have its effects turned off almost immediately. If we remember, epi is metabolized very fast in the body IV (within 10mins) With SQ/IM epi, the effect is sustained and can't be turned off. 

1mg of epi in a liter bag of NSS gives you a 1:1 and is a pretty safe concentration for IV.


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## jwk (Apr 23, 2012)

the_negro_puppy said:


> Our Icps give epi/adrenaline for:
> 
> Bradycardia with poor perfusion unresponsive to atropine and or pacing
> Shock (exuding haemorrhagic) unresponsive to fluid
> ...



I'm assuming you mean 20-50m*c*g


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