Dopamine in Sepsis?

[Summit]

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.

 

[NPO]

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]

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.

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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...

 

[VentMonkey]

@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.

 

[NPO]

@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]

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

 

[Summit]

IRRC Epi is the most effective in extreme pHs

Would love to read that paper

 

[VFlutter]

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.

 

[Carlos Danger]

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.

 

[VFlutter]

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.

 

[FLMedic311]

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.

 

[Summit]

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

 

[RocketMedic]

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.

 

[E tank]

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.