PFC Podcast: Vasopressors and Shock Management

0:00Rinse snows that greatness takes time, but soda's laundry. So rinse will take your laundry and hand-deliver it to your door, expertly cleaned. And you can take the time pursuing your passions. Time one spent sorting and waiting, folding and queuing, now spent challenging and innovating and pushing your way to greatness. So pick up the Irish flute or those calligraphy pens, or that daunting beef Wellington recipe card, and leave the laundry to us. Rinse, it's time to be great. Welcome back to the PFC podcast. The views and opinions you are about to hear are the speakers, and do not necessarily reflect those of anyone else. Now on to the podcast. Welcome back to the PFC podcast, this is Dennis, and today I'm with Doug. How are you doing today? Better than a pesky spring cold, I'm doing great, thanks, that's perfect, perfect.

1:01So you introduced yourself a couple of weeks ago, working in the cardiothoracic ICU. So I thought you would be the perfect guy to ask this question about vasopressors, how to use them appropriately. Great, bread and butter. It's bread and butter for you. So you look in the sepsis, CPGs, you look in essentially any other distributive shock things, right? But especially sepsis, they talk about using norepinephrine, they talk about vasopressin, debutamine, and kind of epi is like kind of the back shelf type of stuff. Why do they stick me with epi and all the good stuff goes to you guys? Well, it's not so much that we stick you with epi, it's sort of more of a, but where

2:04the man with one gun analogy, that in soft medicine is in many things soft, that items that have multiple uses are probably going to take precedence over items that do not, right? And so in the case of vasopressors, or cataclylamines, epinephrine has multiple uses, you can use it in cardiac arrest, you can use it as a vasopressor, you can use it in anaphylaxis, where it is first fine, that's not, you know, off the reservation. And so the thought was, the rationale behind having epinephrine be the vasopressor choice for far forward medicine is that, you know, if you get comfortable, or as comfortable as possible, learning one of these very complicated drugs with very serious side effects,

3:12better than having three or four that you never get familiar with. Yep, no, I think it's a wise choice. I think it's very versatile, and we still don't learn it really well. No, and in prepping for the podcast, you know, there's, there are actually arguments to be made against epinephrine, because the nomenclature has now become so confusing, which I'm happy to get into if you want, and, you know, and if, you know, somebody who works in an ICU full-time is confused by all the different naming conventions and concentrations and naming of the concentrations, then, you know, I think it is confusing. I think, you know, an 18 delta could make an argument for taking more epinephrine, which comes in one concentration, and, you know, is a great presser, has fewer of the arrhythmic

4:13side effects, and doesn't, you know, break down the lactic acid, and epipens for anaphylaxis. I mean, I think, and if you want to get to alternative strategies for load out of sometime in the podcast, you know, we can discuss that. Oh, perfect. So speaking of those horrible side effects that happen, like I hit somebody with epinephrine, what kind of things should I expect? The biggest risk of, of giving epinephrine is really if the high, yeah, I guess high concentration dose, the milligram per milliliter dose, formerly known as the 1 to 1000 dose or the code dose epi. If a milligram of that is given IV, you can really jack somebody's heart rate, put

5:19him into an unstable arrhythmia, jack their blood pressure, I mean, into like the 200s over 100s, and potentially cause some hypertension-related side effects, like stroke or inner cerebral hemorrhage. So for that reason alone, number one, I think it's probably not a great idea to carry that concentration, and because the only use for it really is in cardiac arrest, which we're probably not going to be dealing with. And it's a more concentrated inter-muscular dose for anaphylaxis, but you can still get there with a 0.1 milligram per milliliter, the more dilute dose. And so basically pushing undiluted epinephrine IV is your biggest risk. Your other associated

6:19adverse effects, it is because it has more beta-1 effects than noraphynephrine. You can get some arrhythmias. It is used actually to increase heart rate in patients with a brate of cardiac. It's not first-line dopamine is first-line for that, but it certainly can help, and it's more arrhythmogenic than noraphynephrine or vasopressin. And you, and then I guess, what are the other, oh, and the other big side effect is that epinephrine breaks down and tablizes into, like, one of its metabolites is like gaseous. If you use epinephrine in an infusion, probably more than push doses, for long enough period of time at high NF doses, you'll get a lack

7:19of gaseous doses that you'll then have to deal with, or ignore depending on what the GAs does. Score more with the college branded Venmo debit card and earn up to 5% cash back with Venmo stash. Got paid back? With the Venmo debit card, you can instantly access your balance and spend on what you want, like game day snacks, gear, tickets, and more. The more you do, the more cash back you can earn. Plus, there's no monthly fear minimum balance. Sign up now at Venmo.com slash college card. The Venmo master card is issued by the Bank Court Bank NA, select schools available, Venmo stash terms and exclusions apply at Venmo.me slash stash terms. Max $100 cash back per month. This episode is brought to you by Athletic Brewing Company. No matter how you do game day, on the couch, in the crowd, or manning the snack table, athletic brewing fits right in. With a full lineup of non-alcoholic beer styles, you can enjoy bold flavors all game long. No hangovers, no buzz, no subbing out for water in the second half. Stuck the fridge for tip off with a variety of non-alcoholic craft styles available at your local grocery store or online at AthleticBruing.com. Near beer, fit for all times.

8:28Like, when would something like that be a real problem? Well, when would the Lactic Acidosis be a problem if you're running it as an infusion? You know, we see it in our part patients who come out and they're on some nor up an effort, they're on some up an effort. And they probably have some of them have a Lactic Acidosis anyway, just because of the stress of surgery and maybe they're all hyper-volinic. But then, you know, as you go on and resuscitate them and they'll like the Lactic Acid stuff, climbing, you kind of have to attribute that to the epinephrine. So, yeah, so that's not a great side effect of it. Yeah, but the risk is coming from the pH. The risk comes from the pH, right? If you have a Lactic Acid 6 and the pH of 7.4,

9:30you have a clinically less significant Lactic Acid level than if you had a Lactic Acid 6 and the pH of 7.1. The challenge in our environment is we don't really have a way of measuring pH. You're going to have to kind of back your way into figuring out that your patient's has a panic as you talk about it, I think, another podcast. We don't measure it, it doesn't matter. What's that? If you don't measure it, it doesn't matter. If you don't check it, everything's going to be all right. But, you know, if they're bleeding, if you're going up and up on your pressers and they're not responding, those are all kind of signs that maybe you have a clinical significant acidosis. But, again, it's a not so desirable side effect of epinephrine, given as a presser. So, again, like the sepsis CPGs, more specifically, my first thing is giving fluids.

10:40A lot of the research papers out there are saying we need to move pressers early. That's okay. We need to move fluid or sorry, pressers early and not give so much fluid. So, the temptation, I think, on my side is to jump directly into pressers. What do you think about fluids? Should we be bothering with it? I would like to not have to carry it. No, we should definitely be bothering with fluid, especially for sepsis, excuse me, because that is the gold standard for sepsis, for sepsis precipitation. And we deviate from that only because we have to, not because we can. So, carry your fluids, get your fluids in. The so-what of jumping to pressers without giving fluids is that giving

11:45pressers in an unresuscitated patient is probably going to cause more harm than good. Right. So, you get septic, it's a distributive shock, your blood vessels dilate. You know, now you've got five liters of fluid in a 10 liter vessel as opposed to five liters of fluid in a five liter vessel. And so, the pressure, there's going to be a lot of empty space in there. Right. And if you don't fill that space back up with some inner vascular volume and you start squeezing down, you may not get enough preload in the heart and the heart may overwork and not function well or not function at all. So, you've got to have something in the ventricles for the heart to squeeze out. And if you, if you don't replace the fluid that's been lost in

12:49type of, in type of a lemic shock or the fluid that's been third-spaced and is hiding out in the blood vessels under lower pressure in distributive shock and inflammatory response, then you know, your pressers are going to do it again. Okay. No, it makes a hundred percent sense. So, the substance CPG and I'm guessing the same could be true for anaphylactic patient who's becoming hypotensive as well. Yeah. And in fact, you know, it read a little bit more about anaphylaxis for the podcast because that's just not something that we see very often. The most, most anaphylactic shock in the hospital is dealt with in the emergency department. It's very rare that it happens in the, in the, on the floor. It does. You know, because we have a drug reaction and I've definitely had had cases of it. But just to be familiarize myself with it and it is really the mother of all distributive shocks.

13:50It's like, you know, all of a sudden somebody just turns a dial and your blood vessels go like that and, you know, your fluid volume, the inner vascular volume pressure goes like that. And the treatment for that first and foremost actually is fluids. Because number one, that's what you've got on hand, probably is what you can get on board the quickest. Number two is you really do have some inner vascular volume that's been lost through third space and you need to replace. And yeah. So, so volume resuscitation has an equally, if not more important role in anaphylaxis as it does in, in substance. And in fact, the guidelines for anaphylaxis for starting an happy infusion, say only in patients that have low blood pressure that is resistant to

14:53repeated doses of api-patter, pristas, inner vascular, api, and volume resuscitation. Only in that case do you think about starting an api-patter. Okay. Okay. It does. It does. So, fluid-wise, the substance EPG says 30ccs per kilogram within three hours. Now, does that mean I hang a giant bed bag of lactated ringers and drip that in over three hours? No, just like with burn resuscitation, it's really a, it's not a target that you have to hit. It's a guideline for how much fluid the patient might need, right? And if their blood pressure normalizes or gets good enough, stable and adequate enough pressure, and by that, I mean, I mean arterial pressure of like 60 to 65 millimeters of

15:58mercury and stable. And they have signs that their organ perfusionism is improving. The skin is not modeled if urine output is something 20, 30ccs an hour. Their mentation improves if they're not sedated and insubated already. Then, you know, you can back off. So, would I be safe to do like 500 to a liter of bolus? See how they respond? And if I win, then I stop. If I don't, then maybe another 500 and use that 30ccs, it's like a cutoff. Not so much a cutoff. It's more like I said, I actually believe that the the sepsis, the ribon-sepsis guidelines sort of do encourage you to give that much, but I think that, most practitioners would see that as a suggestion of how much the patient might need, not a slam

17:01all this in every patient in the first three hours in every sepsis case. So, you know, we certainly see the complications of burn resuscitation and sepsis resuscitation is no different. It's usually less volume, but excuse me. You know, I'm always a little wary of guidelines that say, you know, put in this target volume of fluid in all patients every time. Yeah. Yeah. I mean, I don't know. Maybe I'm slow to the game or what, but I think when never, anybody is writing guidelines or a CPG or whatever, they have a specific patient in mind when they're writing it. And sometimes your patient doesn't match. Yeah, you know, if your patient is 100 kilos and my patient is, you know, 38 kilos, I mean, I guess it is, you know, CCs per kilo,

18:09but my patient is going to need less fluid, which that guideline does it draws. So, you know, I'd say it's out there as a recommendation for, hey, these patients can need a lot of fluid. You know, start giving it, give it quickly. You know, get their antibiotics on board quickly and assess their response. And if they stabilize, you can back off. And if they don't, you may need to go, you know, the whole way and then keep going. Patients, there's some fascinating case reports out of the Ebola epidemic in Africa, you know, back in 2010s or what 2010s? Because it happened right after I got to, to my posting down here in North Carolina. And they were getting, you know, 20 leaders of fluid over the course of the hospitalization. Just because they're volume losses,

19:16we're so immense in the third space of the siblings. So, when I'm given some fluids, I'm not really waiting, but I haven't also reached my end state with amount of fluids. I'm, there have been at least written down in the guidelines. When do you say, foods aren't working, start squeezing them? Two cases. One is if you can deduce from the history or from a bedside ultrasound that your patient has heart failure, then you're probably not going to hit them with a whole 30 CCs per kilogram before you start a presser. Excuse me. You know, you might hit them with 500, and another 500, if they come up great, but if they're not, that's when you might want to move to a presser. I am. So, we just asked you about, you know, when to press, we're talking about,

20:23you mentioned heart failure, I'm giving them fluids, I'm not really getting much of a response out of it. I think the other place you'd move to a presser early is, you know, you're aggressively resuscitating them, you have your first liter in, you know, you start that, open it wide open, and the patient is just profoundly set, like their map is like in the 40s or 50s, you know, like low 50s. And you put that, and you put that first liter of fluid in and it doesn't buy much, and you may want to, you know, give them a push-dose of epi or start a drip, you know, just to give them some sort of a perfusion presser as you're resuscitating them. And then, you know, who knows, they may respond to volume, and they just need it some time, and you can back off on the presser, or they may be that sick that it's going to take a combination. Usually it's door number two. Usually if they're sick enough to not respond to volume, to bring their blood

21:29pressure off, they're going to need a presser, and they're going to need it for a while. Cover it at least. Okay, it does, it does. Now, I carry multiple epi pens. I also carry many, a plethora of one CC, one milligram per ML epinephrine. I can squeeze them and get this high of blood pressure as I want. However, I do know that you don't necessarily want to do that. How far, like, what are my end goals, you know, like, I read the guidelines with epi use, it says like, you know, five micrograms per minute all the way out to like 20 micrograms per minute. That's a fourfold increase. Right. It's interesting, because the guidelines are a lot broader than what I've seen epi use and clinical use. You know, five micrograms in 100 kilogram person is like

22:360.05 micrograms per kilo per minute. And that's, you know, sort of on the moderate end of the starting dose for us. You know, we'd probably start at 0.02. You know, we get to 0.05 a lot on people, but we tend to not run it more than 0.5, which would be, you see, what would 0.5 be? 5 micrograms per minute. And you said 5 to 20 micrograms per minute. Yes, the 20 would be 0.2. Yeah, that's about reasonable. Yeah, because 20 micrograms per minute, the 100 kilo guy would be 0.2. No, it would be 2. Yeah, it'd be 0.2 micrograms per kilo per minute.

23:39Yeah, that's fine. We generally run up to 0.3. So actually, that's fine. Okay. So good. I have room on the far end. You got room on the far end. And I just did math in public, which is a very hot, a fraught exercise. Set yourself up for that one. Well, and, you know, fraught and super risky with something like epinephrine. So if you do the metron, right? So, but no, that's actually, that's, if you're just going to go micrograms per minute, that's not that bad. Where you get into trouble, though, is if you're doing that dosing range in somebody who's lighter. So 50 kilogram per cent double those doses, right? That's 0.1 to what did I say? 0.2.4. You're still probably okay. So I think what I found at least with like my narcotic use starts chart low. I can always go higher. Correct. Always start low. What am I looking for?

24:46Basically, you're looking for a response of blood pressure, right? Epi is very rapid onset, you know, within seconds. It's very short duration, which is why pushdose epi is great for getting somebody stable while you're mixing a drip, but you wouldn't really want to do it. It's not like pushdose ketamine where, you know, you're good for 20, 30 minutes. Pushdose epi is like you might be good for 10 if you're lucky. So you're going to see if, you know, you're going to see a response to epi within seconds. Yes. So good blood pressure. Yeah, map of 60, 65 millimeters of mercury. And again, all the other markers of resuscitation, you know, I'll place some urine output. You know, good caprifil. Caprifil modeling as well. Okay. So tone comes back in tone, skin color comes

25:53back. Hopefully L.O.C. starts coming back. Yes, exactly. And you know, and even if they're sedated, and on an event, they still have, they still have, you still get a neural exam. You can turn your foundation down. You can ask him to squeeze your hand. You know, we get neural exams unscathed in all of the patients all the time. X amount is unpredictable, but you can flare less with epglyce, a once monthly treatment for moderate to superior X amount. After an initial four-month or longer dosing phase, about four and ten people taking epglyce, achieved itch relief and glayer or almost glared skin at 16 weeks. And also those people maintain skin that's still more glared at one year with monthly dosing. Hemglyce, LibriKizumap, LBKZ, a 250 milligram per 2 milliliter injection is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe exema. Also called atopic dermatitis that is not well controlled with prescription therapies used on the skin, or topicals, or who cannot use topical therapies. Epglyce can be used with or without topical corticosteroids. Don't use if you're allergic to epglyce. Allergic reactions can occur that

26:56can be severe. Eye problems can occur. Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine when treated with epglyce. Before starting epglyce, tell your doctor if you have a parasitic infection. Ask a doctor about epglyce and visit epglyce.lily.com or call 1-800-LilyRx or 1-800-545-5979. Spring styles are at Nordstrom Rack stores now, and they're up to 60 percent off. Stock up and save on rag and bone made well. Vince, all saints, and more of your favorites. How did I let no rack as a deedus? Why do we rack for the hottest still? There's so many good brands. Join the Nordy Club to unlock exclusive discounts shop new arrivals first and more. Plus, buy online and pick up at your favorite rack store for free. Great brands, great prices. That's why you rack. Like we said, with predators, you can keep going. You can squeeze them down and now it starts to become dangerous. How do I know when I'm starting to get into that dangerous

28:02zone? There's a map of 65 is good. What's that? I said a map of 65 is good, but 100 would be better. No. Map of 65 is actually all you need. In some cases, it's really, in general, if you're having a hard time, if somebody's really hypertensive, you may have a hard time getting into a goal map. In which case, sick and stable is okay. So a map of 65 is fine. It doesn't take much of a systolic blood pressure to get you there. The diastolic affects it more, because it's two times diastolic plus systolic. The diastolic is more affected by your end of the diastolic volume, which is your cardiovascular volume, and that's where the resuscitation comes in.

29:03Now, it doesn't epi. Would you have a more profound effect on the diastolic side, because you're squeezing it? You'd have both, because it's got beta-1 effects, which is going to increase your cardiac contractility. So every squeeze of the heart, you're going to get more cardiac output, which is going to drive up your systolic, but you're also got alpha-1, which is squeezing the blood vessels, which is going to help both actually, but diastolic for sure. So you're getting that wide pulse pressure from your distributed shock. You should be seeing that thing closing in with the pressure. Yeah. With the pressure, yeah. Any other, so like, end points are good. Hey, all the things that told me this guy's in shock, start winding back. How do I know if I'm starting to get into a dangerous zone?

30:07Sometimes I'm seeing heart rates climbing into the 120s, 130s, 140s. Yeah. Obviously, if you put somebody on an epi rip, more than push, probably, but sometimes both, they give some an epinephrine in their heart rate jumps. That's a concerning side effect, especially if it doesn't come right back down again. If their heart rate is stable and remember, sick patients are attacked a part of too. Patients with sepsis rarely have a heart rate under 100. Yeah. So it's more of the change, right? You know, if there are heart rates 110 because they're sick, and you give them epi and their heart rate stays 110, the disease process is not the epi, or 120 and stays 120. It's more like it is 110 and it goes to 130. That's more. And we do have to change

31:14our selection of pressures and insurbs in the ICU for tachycardia complications. Could that be just to sign that they need some more volume? No. It could be, but it's probably a sign that they're just more sensitive to the drug. And there's no rhyme or reason for who's going to get epi and have a high, a faster heart rate and who's small. So what would you say is like an end point that if their heart rate gets above 150? I'd say it needs just 20 beats a minute or more, and it's probably a time, at least back off, because you know, if you're at a, you know, if you're at a whatever 10 mites per minute rate back down to five, if you can, maybe you have to turn the drug off and walk it back up again. Okay. So maybe go back to your push-doses? Go back to your push-doses. Maybe you have to have regrets and go back to your supply sergeant,

32:17get nor epineph from the next time you deploy. Right. See? We're back to it. They're holding out on us. They're holding out on us. You know, what does, what does nor epineph from do for me? Like why is it the first line? At least for sepsis. Nor epineph is, you know, if I, and it's interesting because, you know, we're talking out of one side of our mouth that epineph is the drug you should carry, and the other side of our mouth is saying, but nor epineph is really got all these things going for it that make it a safer drug in many ways, or maybe not safer, but a drug that's easier to manage in many ways. It's definitely doesn't have the arrhythmia complications that Epi has. It's more of a, it has more alpha effect, right, which is vasoconstricting and less beta effect. Now it does have some beta effect. There is some increase in cardiac contractability that comes with nor epineph, but not

33:23to the extent that epineph has, and very, very little effect on heart rate and bad arrhythmias. So that's, that's the benefit. I generally tell the students and the residents that if they only use, if they only learn one press or, you know, learn nor epineph. So let's say we trade spots. I take your job as said cardiothoracic ICU, which it will be complete chaos, but that's not your problem because here's stuck out in the woods. Would you be okay controlling your sepsis, really bad anaphylaxis? All you got, Epi. Yeah. Yeah. Yeah, because I, you know, it's kind of like the best fluid to use is the one you have, the best presser to use is the one you have. I think all the, all the

34:27cataclysmine vasopressors, at least the big two, epi and nor epi, each have their advantages, each have their disadvantages, you know. Yeah. I might want a block, but if somebody hand me a cold, I'd probably go out and shoot, I'd probably learn how to shoot and defend myself. Yeah. All you got to do is pull the trigger. There's some aiming involved. If somebody, people have to know I usually scares them. No, and maybe the takeaway for all of this is, you know, you're not wrong. If you pull epi and you learn, you learn to use epi because it's got this wide range of effects of uses, right? It's, it's a great drug for cardiogenic shock, which probably is not really big in our community. Hopefully not. It's a great drug for, it's the drug for anaphylaxis.

35:35There's no question about it. You know, anaphylaxis is treated with fluids and epinephrine. That's what you need. If you don't have it, you're not, you know, your patient might not make it. Yeah. And it's a, it's a, it's a decent drug for all, you know, all, high bovellemic and vasodilatory shocks. You just have to know it's side effects. The other strategy would be, you know, you pull Nora up and then afferning you carry that for shock, vasodilatory shock or all shock, except for anaphylaxis and then you carry epi or you carry both and you learn them both. Okay. Or you make cheeses for both in your, in your med box. There was any advice you would want to give to somebody who is alone and afraid just with their epi pens. What would you, what advice would you give? Alone and afraid with an anaphylaxis patient in their epi pens or somebody else in their

36:40epi pens. Anaphylaxis, but he's refractory. So that first dose, because it was delayed. I would start getting some fluids on board. I, you know, and that's a patient who might take two, three liters of fluids. And then, you know, give them a second dose and see how he does and then just better. He gets better. There you go. Then just be vigilant to see, you know, if he's going to need a third dose, you know, if he's going to rebound or break through, if the dose will, you know, live there, effects of whatever the anaphylaxis stimulants are, are over before the epi works off or if they continue and he needs more. Perfect. Thank you, Doug. I really appreciate you walking

37:41me through all this. You're welcome. Not very straightforward. This is like more on the complex side of critical care medicine and certainly austere critical care medicine. Yeah, absolutely. Unfortunately, none of my patients titrate their complexity to my skill. They just kind of show up. They just kind of show up. I love it. Well, thanks for asking me on. I hope I hope it wasn't, I hope it was more clear than mine. I think it was. Good. Appreciate it. All right. Have a good night. Yep. You too, Dennis. That's it for today's podcast. Make sure to go to our website, www.prolongfieldcare.org. Check out our free downloads and a ton of other helpful information. Grab a bag of our fresh roasted PFC coffee, links in the description below and stay on the bleeding edge of combat and austere medicine. Is it Dennis for the PFC podcast? Out.

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