# Push Dose Pressors



## NomadicMedic (Dec 30, 2016)

In another thread, @Bullets mentioned that his service is using Epi as a push dose pressor in "not dead people". Anyone else doing this? Makes sense during a shorter transport. 

Here's a JEMS article. (I know, don't shoot me. It had peer reviewed scholarly citations.)

http://www.jems.com/articles/print/...h-dose-epinephrine-temporizing-measure-0.html


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## TransportJockey (Dec 30, 2016)

We have it for post code resus and for severely hypotensive patients as an alternative to levo. We don't carry Dope or dobutamine, so it's our only other option. I'm actually a big fan of Epi 1:100,000 for hypotension


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## VentMonkey (Dec 30, 2016)

This has been "all the rage" in the SMACC/ FOAMED realm for the past few years.

I think it's worth a shot in certain situations such as what @TransportJockey mentions in his protocols above (I really do think Galveston EMS sounds more and more fitting  for me).

Let's see what the good doc's spin on it is...
@ERDoc anyone?


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## PotatoMedic (Dec 30, 2016)

DEmedic said:


> In another thread, @Bullets mentioned that his service is using Epi as a push dose pressor in "not dead people". Anyone else doing this? Makes sense during a shorter transport.
> 
> Here's a JEMS article. (I know, don't shoot me. It had peer reviewed scholarly citations.)
> 
> http://www.jems.com/articles/print/...h-dose-epinephrine-temporizing-measure-0.html


I believe it will be in the new protocols for Pierce county.  When, IF, they ever come out.


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## NomadicMedic (Dec 30, 2016)

My only option is either Dope or an Epi drip, but I reckon I could get orders for push pressors.


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## VentMonkey (Dec 30, 2016)

DEmedic said:


> My only option is either Dope or an Epi drip, but I reckon I could get orders for push pressors.


We're in the same boat on the ground. CCT has a Levo (gtt) as a third pressor option.

PDP's just seem so much more practical, especially in a post-ROSC patient who is teetering between severe hypotension and re-arresting.


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## Brandon O (Dec 30, 2016)

Either epi or neo pushes are very useful tools in an acute resuscitation or unstable patient.

The latter tend to be easier to come by (we have premade syringes in the Pyxis, anesthesia carries them around in their pocket, etc). Epi you usually have to use the code amps and just (preferably) push small aliquots of it. Never tried to mix it.


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## TransportJockey (Dec 30, 2016)

Brandon O said:


> Either epi or neo pushes are very useful tools in an acute resuscitation or unstable patient.
> 
> The latter tend to be easier to come by (we have premade syringes in the Pyxis, anesthesia carries them around in their pocket, etc). Epi you usually have to use the code amps and just (preferably) push small aliquots of it. Never tried to mix it.


We push out 1 mL from a flush and pull up 1mL from the 1:10,000 for ease of mixing. Doesn't take long either. I know when I run a code, whoever is doing drugs I tell to do that after one of their epi pushes


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## Brandon O (Dec 30, 2016)

TransportJockey said:


> We push out 1 mL from a flush and pull up 1mL from the 1:10,000 for ease of mixing. Doesn't take long either. I know when I run a code, whoever is doing drugs I tell to do that after one of their epi pushes



Yeah, I've heard of that. Dumb question, how do you pull it up? A flush won't screw directly into the Bristojet, right? They're both male connectors.


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## DesertMedic66 (Dec 30, 2016)

Brandon O said:


> Yeah, I've heard of that. Dumb question, how do you pull it up? A flush won't screw directly into the Bristojet, right? They're both male connectors.


3 way stopcock?


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## NomadicMedic (Dec 30, 2016)

DesertMedic66 said:


> 3 way stopcock?



That's Dr Antevy's thing.


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## DesertMedic66 (Dec 30, 2016)

DEmedic said:


> That's Dr Antevy's thing.


That's where I got it from..


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## NomadicMedic (Dec 30, 2016)

You could also stick an 18 on the flush and draw up from the amp. (Once you flip that yellow cap off, there's a rubber stopper in there)


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## MonkeyArrow (Dec 30, 2016)

I feel like pharmacologically speaking, phenyl would be a better choice for push dose pressors due to its quick half life and relatively clean mechanism.

I know that it's not an option pre-hospitally for most (all?) of us, but I feel like would be a more appropriate in hospital drug choice.


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## TransportJockey (Dec 30, 2016)

DEmedic said:


> You could also stick an 18 on the flush and draw up from the amp. (Once you flip that yellow cap off, there's a rubber stopper in there)


This is how we usually do it. Stopcocks can be hard to come by on our trucks right now 

Sent from my SM-N920P using Tapatalk


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## NomadicMedic (Dec 30, 2016)

stopcock - the girl at the bar who's friends with the girl you're hitting on and keeps saying things like, "it's time to go Jennifer!"


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## Brandon O (Dec 30, 2016)

DEmedic said:


> You could also stick an 18 on the flush and draw up from the amp. (Once you flip that yellow cap off, there's a rubber stopper in there)



Needle through the stopper, or you remove the stopper?



MonkeyArrow said:


> I feel like pharmacologically speaking, phenyl would be a better choice for push dose pressors due to its quick half life and relatively clean mechanism.



Ehh. This is the initial feeling most of us have about phenylephrine -- seems like pure vasoconstriction is a good match for what we often want -- but really it's usually not the case. Its best fit is probably for purely sedative-related hypotension -- you gave some propofol or fentanyl or gas or whatever and dropped their pressure -- which is primarily related to reduced SVR (although even that's a simplification as most sedatives are also negative inotropes). Great, give some Neo. But in most situations, pure vasoconstriction is not actually ideal, because it increases their afterload without giving any inotropic assistance to push against that afterload. Someone with a really good young heart may be able to power through that high gear, but many need help.

That's largely why norepinephrine has become our go-to pressor drip for most situations; it gives vasoconstriction with just enough beta to stay balanced.


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## StCEMT (Dec 30, 2016)

I'd like this. Often have a short transport time, being able to do this would be less cluttered.


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## SpecialK (Dec 30, 2016)

We just put 1 mg of adrenaline in a 1 litre bag of NaCl and adjust the infusion rate to the patient condition.  Single bolus doses of vasopressor from a syringe have been withdrawn.  This approach is much easier than fart arseing around with syringe boluses and it has reduced dosing error.


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## TXmed (Dec 30, 2016)

I just squeeze out 9ml of epi 1:10 pre-filled, hook it to a saline bag that is running and draw back 9ml of saline. (wasteful i know but fast and easy).

I love push-dose epi, i think epi as a whole is under utilized and often times people act scared of it. But i think epi drips and push-dose are a thing of the future for pre-hospital.


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## VFlutter (Dec 30, 2016)

We used push dose neo extensively in the ICU and it is great in certain situations such as peri/post intubation hypotension or shocky patients while you are mixing drips however sometimes I think providers use it as a crutch and not properly resuscitate the patient. The classic "We gave 5 neo sticks on the way" so they maintain their pressure just long enough to arrest for you.


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## ERDoc (Dec 31, 2016)

VentMonkey said:


> This has been "all the rage" in the SMACC/ FOAMED realm for the past few years.
> 
> I think it's worth a shot in certain situations such as what @TransportJockey mentions in his protocols above (I really do think Galveston EMS sounds more and more fitting  for me).
> 
> ...



This is where you get spoiled working in a hospital.  Every hospital I work at has a clinical pharmacologist on 24/7 who can get anything ready pretty quick and EMS does not carry pressors so it is not something I have done much reading on.  I don't see a problem with it, if it is all you have.  In that case it is better than doing nothing.


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## medichopeful (Dec 31, 2016)

I actually wrote a paper on the idea of push-pressors in paramedic school.  I'm a huge fan (I've used them in the ICU too). They're awesome for people who don't necessarily need a drip (post-intubation hypotension), or to buy some time to set up a drip.

I know that Wake County has push-dose neo in their protocols and am rather envious of this (I'm doing ride time in Mass, so take that for what's it's worth).

Here's an EMCrit podcast on this:

http://emcrit.org/podcasts/bolus-dose-pressors/


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## Bullets (Dec 31, 2016)

Brandon O said:


> Yeah, I've heard of that. Dumb question, how do you pull it up? A flush won't screw directly into the Bristojet, right? They're both male connectors.



put the epi in a bristo, screw a med draw needle on the end, waste 1ml from a flush and push 1ml of epi into the flush


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## VentMonkey (Dec 31, 2016)

However it's drawn up,it seems more than reasonable that this should be something taught to be the norm---as mentioned---in any post-ROSC/ severely hypotensive patients at the very least.

Particularly with shorter transport times when hanging drips seems time consuming, and less practical with these types of patients, specifically.


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## TXmed (Dec 31, 2016)

With the growing popularity of this, it wouldnt suprise me if we saw epi 1:100 prefilled in a few years.


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## Carlos Danger (Dec 31, 2016)

TXmed said:


> With the growing popularity of this, it wouldnt suprise me if we saw epi 1:100 prefilled in a few years.


You can find that in many hospitals.


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## TXmed (Dec 31, 2016)

Remi said:


> You can find that in many hospitals.



Interesting, ive havent seen it in the prehospital setting.


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## Carlos Danger (Jan 1, 2017)

TXmed said:


> Interesting, ive havent seen it in the prehospital setting.



The only settings I've seen it used routinely is in cardiac surgery and ped anesthesia. But lots of hospital pharmacies stock it.

Ephedrine is essentially the same drug, and can be found anywhere. In anesthesia I've never seen or heard of anyone using epi routinely (outside of the aforementioned settings) because ephedrine is easier to use and so readily available.

I don't know why more people don't stock ephedrine rather than messing with epi.


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## Brandon O (Jan 1, 2017)

Remi said:


> I don't know why more people don't stock ephedrine rather than messing with epi.



Kinda longer acting, right?

What are the pharmacodynamics like (alpha/beta)?


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## Carlos Danger (Jan 1, 2017)

Ephedrine is much longer acting than epi. It has both direct and indirect effects and is more alpha than beta, which is the opposite of epi, and is probably more useful for most clinical scenarios and it causes less tachycardia at equivalent doses. It's also "cleaner", in terms of having fewer effects on endogenous steroids and other hormones. Not emetogenic like epi is. The two drugs have similar effects on renal, coronary, and cerebral perfusion. 

The only real advantage that epi has over ephedrine in most scenarios is that epi takes effect much quicker. Ephedrine takes a full minute or two.


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## Brandon O (Jan 1, 2017)

Remi said:


> Ephedrine is much longer acting than epi. It has both direct and indirect effects and is more alpha than beta, which is the opposite of epi, and is probably more useful for most clinical scenarios and it causes less tachycardia at equivalent doses. It's also "cleaner", in terms of having fewer effects on endogenous steroids and other hormones. Not emetogenic like epi is. The two drugs have similar effects on renal, coronary, and cerebral perfusion.
> 
> The only real advantage that epi has over ephedrine in most scenarios is that epi takes effect much quicker. Ephedrine takes a full minute or two.



I think the typical reasoning for the crashing patient is that a fast on, fast off med is desirable, that when paired with phenylephrine it covers a good range of vasoconstrictive vs cardioactive effects, and probably most of all that it tends to be familiar to us and immediately available outside the OR (if only in the code cart), whereas I've never seen an ephedrine stick within shouting distance.


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## Carlos Danger (Jan 1, 2017)

Brandon O said:


> I think the typical reasoning for the crashing patient is that a fast on, fast off med is desirable, that when paired with phenylephrine it covers a good range of vasoconstrictive vs cardioactive effects, and probably most of all that it tends to be familiar to us and immediately available outside the OR (if only in the code cart), whereas I've never seen an ephedrine stick within shouting distance.


Maybe. I've only used epi maybe a few dozen times outside of a cardiac arrest. But we deal with "crashing" patients daily in the OR, and ephedrine and neo (and vasopressin and calcium) is pretty much all we use.

Cardiac OR is a different story. They push all kinds of weird stuff. Milrinone, nitrates, norepi, everything.


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## Brandon O (Jan 1, 2017)

Remi said:


> Maybe. I've only used epi maybe a few dozen times outside of a cardiac arrest. But we deal with "crashing" patients daily in the OR, and ephedrine and neo (and vasopressin and calcium) is pretty much all we use.



Granted, but (as you say, outside of cardiac cases) I imagine this is mostly folks with okay hearts experiencing either a little more vasodilation than you planned (due to sedation) or perhaps getting a little behind on volume. In other settings there may be more of a need for a chronotrope/inotrope.


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## TXmed (Jan 1, 2017)

Remi said:


> Maybe. I've only used epi maybe a few dozen times outside of a cardiac arrest. But we deal with "crashing" patients daily in the OR, and ephedrine and neo (and vasopressin and calcium) is pretty much all we use.
> 
> Cardiac OR is a different story. They push all kinds of weird stuff. Milrinone, nitrates, norepi, everything.



Interesting sir, my base (and immediate area) have had a recent cluster of cardiac patients requiring RSI  (late stage CHF, STEMI, balloon pump). and ive been working my hardest to find educational materials that can outline airway plans for these patients as i absolutely hate the "classic RSI" thought process. Maybe ephedrine push as apposed to an epi push can be better for these patients? possibly less stress on the heart itself?


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## Carlos Danger (Jan 1, 2017)

Brandon O said:


> Granted, but (as you say, outside of cardiac cases) I imagine this is mostly folks with okay hearts experiencing either a little more vasodilation than you planned (due to sedation) or perhaps getting a little behind on volume. In other settings there may be more of a need for a chronotrope/inotrope.


Yeah, generally the mechanism for hypotension that you see under GA is primarily vasodilation. But we do put plenty of sick people to sleep, and the cardiac effects of everything we do is in the forefront of our minds. This is why we generally try to a balanced and "gentle" response to hypotension. 

Very broadly speaking, I think the worst thing you can do for a sick heart is to make it beat any faster than necessary.  Tachycardia does much more to tip Mv02 balance in an undesirable direction than does increasing wall tension / afterload. At least without an echo to guide your pharmacotherapy precisely, I think a good general approach to hypotension in a sick person is a fairly balanced mix of volume replacement and alpha1 and beta1 stimulation, with a little more squeeze than cardiac stimulation. Which is exactly what you get from ephedrine.

When I think about the scenarios that EMS is going to be using pressors, I'm thinking more about post-RSI and sepsis-related hypotension than I am pump failure. In the post ROSC patient who has already gotten epi, just start a drip. Certainly there are times where more alpha is needed, but there are reasons why epi drips are rarely used in the ICU's. Those are the same reasons why epi boluses might not be the very best choice.

In actual practice, dilute epi boluses vs. ephedrine boluses is probably a wash in 99% of cases. And if it's all you've got, which is the often the case, then by all means use it. I was just making the point to TXmed that if you want to find prefilled syringes of epi and can't find any, just get your hands on ephedrine instead.


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## E tank (Jan 1, 2017)

IME, it's important to recognize the purpose of an inopressor bolus beyond raising the blood pressure...a quick temporizing whack of neo,epi or whatever to offset a brief period of hypotension after a hypnotic and intubation is one thing and giving vasomotor tone/isotropic support post resus is another set of goals. Even then, epi  vs ephedrine or even vasopressin should be followed by an infusion of something.

Bolus after bolus when a drip is called for is shadow boxing.... happens in the OR all the time .


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## Carlos Danger (Jan 1, 2017)

E tank said:


> IME, it's important to recognize the purpose of an inopressor bolus beyond raising the blood pressure...a quick temporizing whack of neo,epi or whatever to offset a brief period of hypotension after a hypnotic and intubation is one thing and giving vasomotor tone/isotropic support post resus is another set of goals. Even then, epi  vs ephedrine or even vasopressin should be followed by an infusion of something.
> 
> Bolus after bolus when a drip is called for is shadow boxing.... happens in the OR all the time .



Nice to see another gas passer on here. . Nova1300 is an anesthesiologist who primarily does critical care and always shares really useful insight when he posts, and JWK is an AA and old paramedic who posts from time to time. I was a ghettomedic, then a flight paramedic and then a flight nurse up until 2012 when I started CRNA school.


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## Carlos Danger (Jan 1, 2017)

TXmed said:


> Interesting sir, my base (and immediate area) have had a recent cluster of cardiac patients requiring RSI  (late stage CHF, STEMI, balloon pump). and ive been working my hardest to find educational materials that can outline airway plans for these patients as i absolutely hate the "classic RSI" thought process. Maybe ephedrine push as apposed to an epi push can be better for these patients? possibly less stress on the heart itself?



There are a couple different ways to approach a sick cardiac patient who needs to be induced for intubation. I don't have a ton of experience with patients like this, but when I do go to the ICU to tube a sick patient with a big cardiac history I like to use a healthy but not huge dose of fentanyl (1-2 mcg/kg) and about a 1/4, maybe a half dose of etomidate. Those are just the drugs I'm familiar with, mostly from my HEMS days, honestly. I'll then cycle the BP as soon as I inflate the balloon, and I always have neo and ephedrine ready. Other folks prefer ketamine, but I haven't become a big fan of it yet as anything other than an opioid-sparing agent during GA. Some people give their pressors at the same time as their induction drugs, which is probably a good idea, but takes some more experience with this population than I have. Some folks just use really small doses of induction drugs and rely on the sympathetic response to the intubation, with the reasoning that all you really need in these cases is some amnesia.

Like I said before, I think ephedrine might be a better agent than epi for these purposes, but I don't have any data to back up that opinion. It's just how I see it, considering my understanding of the drugs and my experience with them.

I think for your purposes, just put your IVF under some pressure, go lighter on your induction agents, and be ready give a small dose of whatever pressor you have available is probably the way to go.


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## TXmed (Jan 1, 2017)

I have a decent amount of experience with different kinds of dosing with ketamine for induction but none with etomidate (ive only used 0.3mg/kg), i guess with the popularity of ketamine the education on etomidate and different ways you can use the drug for induction have dwindled.


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## Carlos Danger (Jan 1, 2017)

TXmed said:


> I have a decent amount of experience with different kinds of dosing with ketamine for induction but none with etomidate (ive only used 0.3mg/kg), i guess with the popularity of ketamine the education on etomidate and different ways you can use the drug for induction have dwindled.


Etomidate is not not nearly as versatile a drug as ketamine. But it's what I did my first couple hundred RSI's with, so I'm used to it. It's very reliable, it gives a very dense anesthesia / amnesia, and it's fairly cardiac stable.


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## TXmed (Jan 1, 2017)

at dosing ranges *LESS* than 0.2-0.3mg/kg does it provide good enough anesthia ?


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## E tank (Jan 1, 2017)

TXmed said:


> at dosing ranges *LESS* than 0.2-0.3mg/kg does it provide good enough anesthia ?



Anecdotal experience being what it is, I've used 2/kg lidocaine for ICU intubation. Point being, the patient will determine what's enough in those situations. 

As for inopressor pushes, there are those times where even whack after whack of epic is useless and the difference between collapse or not is a unit or two of vasopressin. Been there often enough to bring a vial with me to the unit for tubes.


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## Carlos Danger (Jan 1, 2017)

TXmed said:


> at dosing ranges *LESS* than 0.2-0.3mg/kg does it provide good enough anesthia ?



In a sick, hypotensive patient, yes. You can halve that, easily.

Think about what you are trying to accomplish with your induction agent.

In a hypertensive TBI who is already obtunded anyway, you primarily just want to blunt the spike in ICP that follows laryngoscopy and ETI, so you need to use a beta blocker or a large dose of an induction agent or plenty of fentanyl to do that. In reality, in most of those cases you could just give some lidocaine and some esmolol and be just fine.

If, however, your primary goal is prevent a depression of hemodynamics, then your goals are the exact opposite.......you want to use a much smaller doses of any depressant meds.

It doesn't take much of an induction agent to provide some anxiolysis and amnesia. Sure, in a perfect world, our patients would be completely comfortable and unaware of anything. But when it comes to sick patients in the field, the world is far from perfect, and preserving hemodynamics takes priority over everything else.


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## Brandon O (Jan 1, 2017)

Remi said:


> Very broadly speaking, I think the worst thing you can do for a sick heart is to make it beat any faster than necessary.  Tachycardia does much more to tip Mv02 balance in an undesirable direction than does increasing wall tension / afterload.



Mostly I agree. Although one could also argue that with a sick heart -- i.e. a decompensating patient where pump failure is a significant contributor -- they likely need more, not less cardiac support. But now we're getting into nitpicking between the patient with coronary artery disease and the one with cardiomyopathy and really at the end of the day I don't disagree with you.

I suppose my only real point was that there are folks in whom pushing a pure vasoconstrictor (neo) is probably not hemodynamically optimal. Epi may or may not be the best solution to this, but it's usually around in the ICU setting (and in the field). It MAY be the "best" choice for a last-ditch, patient-is-dying push, but calling anything "best" in that case is a bit rich.

We could probably really kick this discussion up a notch by bringing in the AS or PAH patients. But then I'll just get all sweaty.


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## Carlos Danger (Jan 1, 2017)

Brandon O said:


> I suppose my only real point was that there are folks in whom pushing a pure vasoconstrictor (neo) is probably not hemodynamically optimal. Epi may or may not be the best solution to this, but it's usually around in the ICU setting (and in the field). It MAY be the "best" choice for a last-ditch, patient-is-dying push, but calling anything "best" in that case is a bit rich.
> 
> *We could probably really kick this discussion up a notch by bringing in the AS or PAH patients. But then I'll just get all sweaty*.



I would, too, lol.

I'd be happy to talk about that, though. I'd love to hear about the ICU perspective of managing an AS or PAH patient from an ICU perspective. I know what we do in the OR, but if you have a septic patient in the ICU with severe AS, how does that affect your management?


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## Brandon O (Jan 1, 2017)

Remi said:


> I would, too, lol.
> 
> I'd be happy to talk about that, though. I'd love to hear about the ICU perspective of managing an AS or PAH patient from an ICU perspective. I know what we do in the OR, but if you have a septic patient in the ICU with severe AS, how does that effect your management?



Not sure how much I can say that would be especially clever. I would more heavily push preload and try to avoid aggressive afterload increases (although in the end you need what you need). Maybe someone can do a balloon valvuloplasty or something. Mostly, and this goes double for the PAH folks, it's the Goldilocks principle -- maintain euboxia. These are not the people to get laissez faire about their pressure, oxygenation, ventilation, etc, or you may fall down a spiral you can't get out from. 

But in reality this is getting pretty far into the specialty realm where the right thing to reach for is a telephone. I can talk about floating a Swan in the severe PAH patient or starting pulmonary vasodilators, but if they're not already in a shop with things like mechanical support/bypass and cardiac surgery and a real CCU (not my current place), they probably ought to be. I expect you feel similarly.


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## VFlutter (Jan 1, 2017)

Remi said:


> I would, too, lol.
> 
> I'd be happy to talk about that, though. I'd love to hear about the ICU perspective of managing an AS or PAH patient from an ICU perspective. I know what we do in the OR, but if you have a septic patient in the ICU with severe AS, how does that affect your management?



If we are talking push dose pressors I would not be too concerned by the transient increase in afterload from 200-300mcg of Neo even in an severe AS patient. But like anything else it's risk vs benefit. What will kill them first, the profound hypotension or the potential for cardiac decompensation. I suppose using Epi with beta and alpha may be more desirable in that situation.


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## E tank (Jan 1, 2017)

Brandon O said:


> We could probably really kick this discussion up a notch by bringing in the AS or PAH patients. But then I'll just get all sweaty.



I'm in too... let's throw in severe mitral insufficiency...OR is second to second management. How do you guys in the unit prioritize your management goals?


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## E tank (Jan 1, 2017)

Chase said:


> If we are talking push dose pressors I would not be too concerned by the transient increase in afterload from 200-300mcg of Neo even in an severe AS patient. But like anything else it's risk vs benefit. What will kill them first, the profound hypotension or the potential for cardiac decompensation. I suppose using Epi with beta and alpha may be more desirable in that situation.



Yep... you got it, but without the increase in HR... so raise the arterial resistance and the contractility and you've really got it.


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## Brandon O (Jan 1, 2017)

E tank said:


> I'm in too... let's throw in severe mitral insufficiency...OR is second to second management. How do you guys in the unit prioritize your management goals?



I'd say etiology matters. Acute MR from a pap muscle rupture or ischemia really just needs surgical management. More chronic may be better tolerated. But basically reduce/limit afterload (nitroprusside?), keep up the rate and squeeze (epi?), sinus rhythm (amio?), euvolemic to dry, maybe a balloon pump. Manage like HFrEF.

Far from an expert.


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## E tank (Jan 1, 2017)

Brandon O said:


> I'd say etiology matters. Acute MR from a pap muscle rupture or ischemia really just needs surgical management. More chronic may be better tolerated. But basically reduce/limit afterload (nitroprusside?), keep up the rate and squeeze (epi?), sinus rhythm (amio?), euvolemic to dry, maybe a balloon pump. Manage like HFrEF.
> 
> Far from an expert.



Nice... don't know what HRrEF is but you're on the right track... issues...phtn, a fib, arterial resistance, diastolic failure for starters...ef may be preserved or not. Goals... venous return to LV (by mitigating effects of phtn on the RV), optimize arterial resistance for LV out flow (I HATE SNP, prefer nicardipine), HR 80-95 or so, milrinone maybe with some vaso...or just epi, but it can drive PA pressures...

Getting technical here, but the principles are what are important... lots of ways to skin a cat...


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