Feline Hypotension VetGirl FINAL NO PICS · 7/17/14% 1% Tackling)Feline)Hypotension) Christopher)G.)Byers,)DVM,)DACVECC,)DACVIM)(SAIM)) MidWest)Veterinary)Specialty)Hospital) Omaha,)Nebraska)USA)

7/17/14%

1%

Tackling)Feline)Hypotension)

Christopher)G.)Byers,)DVM,)DACVECC,)DACVIM)(SAIM))

MidWest)Veterinary)Specialty)Hospital)

Omaha,)Nebraska)USA)

[email protected])

@CriMcalCareDVM)

www.criMcalcaredvm.com!

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7/17/14%

2%

LogisMcs:)CE)CerMficates)

!  No%need%to%raise%your%hand!%

!  Type%in%ques=ons%

!  Emailed%to%you%48%hours%aWer%the%webinar%

!  Ac=ve%par=cipa=on%=%no%quiz%

!  Watching%video%later,%must%complete%quiz%

!  ELITE%members%only%

!  Email%/%contact%with%ANY%ques=ons%

!  [email protected]%

!  [email protected]%

Call)in)from)Smart)Phone!)

Christopher%Byers,%DVM,%%DACVECC,%DACVIM%(SAIM)%

MidWest%Veterinary%%Specialty%Hospital%

PresentaMon)Layout)

How%do%we%define%hypotension%in%cats?%

What%factor(s)%contribute%to%hypotension%in%cats?%

How%do%we%maintain%AL?%

Defini=on%

Causes%

Cardiac%Output%

SVR%

How%do%we%maximize%PL%and%contrac=lity?%

•  Hypotension!

•  MAP%<60%mmHg%/%SAP%<80+90%mmHg%

•  Preload!(PL)!

•  End+volumetric%pressure%that%stretches%the%right%or%leW%

ventricle%

•  Clinically%measured%by%ventricular%end+diastolic%volume%

•  A5erload!(AL)!

•  Load%against%which%the%heart%contracts%to%eject%blood%

•  Clinically%the%pressure%heart%chambers%must%generate%to%

eject%blood%

• DefiniMons)

CO)=)HR)x)SV)

BP)=)CO)x)SVR.%

•  Stroke!Volume!(SV)!•  Volume%of%blood%pumped%from%one%ventricle%

with%each%heart%beat%

•  Influenced%by%PL,%AL%&%contrac=lity%

•  Systemic!Vascular!Resistance!(SVR)!•  Resistance%to%flow%that%must%be%overcome%to%push%blood%through%the%circulatory%system%

•  Cardiac!Output!(CO)!•  Volume%of%blood%being%pumped%by%the%heart%in%one%minute%

• DefiniMons)

SVR)=)(MAP)–)

CVP))/)CO)

SV)=)EDV)K)ESV))

7/17/14%

3%

•  Early!Goal@Directed!Therapy!(EGDT)!•  Rivers%EP,%et%al%(N!Eng!J!Med,%2001)%

•  16%%reduc=on%in%overall%mortality%and%12%%reduc=on%in%60+day%mortality%

•  With%hypotension%OR%elevated%lactate:%

•  Crystalloid%bolus%(20+40%mL/kg)%or%colloid%equivalent%

•  Target%CVP%8+12%mmHg%

•  Apply%vasoac=ve%medica=ons%if%MAP%<65%mmHg%or%>90%mmHg%

•  If%ScvO2%<70%,%give%pRBCs%to%maintain%PCV%>30%%

•  Consider%mechanical%ven=la=on%to%reduce%pa=ent%oxygen%demand%

• DefiniMons)

EGDT bundle, adapted from Rivers EP, et al (N Eng J Med, 2001)

•  Early!Goal@Directed!Therapy!(EGDT)!•  Why%do%we%care?%

•  Rivers%EP,%et%al%(Curr!Opin!Anesthesiol,%2008)%

•  Reduced%sepsis+related%mortality%by%46%%

•  Shorr%AF,%et%al%(Crit!Care!Med,%2007)%

•  Reduced%hospital%length+of+stay%by%5%days%

•  Reduced%hospital%charges%by%$5,%882%per%pa=ent%

•  Veterinary%evidence+based%medicine%lacking,%but…%

•  Prire%J%(J!Vet!Emerg!Crit!Care,%2006)%

•  Butler%A%(Vet!Clin!North!Am!Sm!Anim,%2011)%

• DefiniMons)

•  Shock%Triad%•  “Triad%of%Death”%

•  Each%point%of%triangle%will%cause%or%contribute%to%severity%of%the%others%

• DefiniMons)

Hypotension%

Hypothermia%Bradycardia%

• Adrenal%medullary%catecholamine%secre=on%

•  Local%release%of%NE%from%post+ganglionic%nerve%fibers%

Increased)

sympatheMc)

output)

Skin,%kidneys%and%viscera%most%affected%

VasoconstricMon)

• DefiniMons)

• Manifesta=on%of%1%or%more:%•  Hypovolemia%

•  Decreased%SVR%

•  Cardiac%dysfunc=on%yielding%reduced%CO%

• Many%issues%contribute%•  Bradycardia%

•  Hypothermia%

•  Anemia%

•  Low%iCa2+%

•  Acidosis%

• Hypotension)Causes)

Reduced)CO)

Hypovolemia.%

Decreased)

SVR.%

7/17/14%

4%

•  HR%<120%bpm%

•  Schwartz%PJ,%et%al%(Circ!Res,%1973)%•  Inadequate%arterial%stretch%triggers%simultaneous%sympathe=c%&%vagal%firing%

•  Reason%for%blunted%tachycardia%response?%

•  Oncken%A,%et%al%(unpublished!data)%•  Series%of%77%hypotensive%cats%(SAP%<80%mmHg)%

•  All%had%normal%or%slow%heart%rates%

• Bradycardia)

Reduced)CO)

•  CO%=%HR%x%SV%

•  General%causes:%•  SA%node%doesn’t%fire%

•  Impulse%conduc=on%blocked%at%AV%node%

•  Idioventricular%rhythms%

•  Need%ECG%to%determine%type%of%bradyarrhythmia%

• Bradyarrhythmia)

Reduced)CO)

Blunted)HR)

response)

Reduced)

peripheral)

perfusion)

Hypothermia)

•  Alpha+1%receptors%(cutaneous)%•  Responsiveness%declines%with%decreased%core%temperatures%

•  Decreased%receptor%affinity%

•  Vasodila=on%

•  Beta+1%adrenergic%receptors%•  Desensi=zed%

•  LV%contrac=lity%reduced%

• Hypothermia)

Reduced)CO)

Decreased)

SVR)

•  Abnormal%rhythms%•  J%waves,%AF,%VF%

• Hypothermia)

Reduced)CO)

Decreased)

SVR)

•  Kishi%K,%et%al%(Anesth!Analg,%2009)%•  Experimental%cat%model;%20%cats%

•  Anesthe=zed%with%pentobarbital%

•  Normothermia%vs.%hypothermia%(32C)%

•  Evaluated%response%of%pial%arterioles%to%hemorrhagic%hypotension%

•  Hypothermia%impaired%autoregulatory%vasodila=on%

• Hypothermia)

Reduced)CO)

Decreased)

SVR)

•  CaO2%=%(1.34%x%Hgb%x%SaO2)%+%(0.0031%x%PaO2)%

•  No%issue%with%dissolved%O2%"%concern%is%Hgb%satura=on%

•  DO2%=%CO%x%CaO2%

•  Compensatory%mechanism%•  Increase%CO%

•  Increase%blood%oxygen%extrac=on%

• Anemia)

7/17/14%

5%

•  Due%to%low%CaO2,%SV%and%HR%(thus%CO)%increase%

•  Normovolemic%anemia%

•  [RBC]%is%major%determinant%of%viscosity%•  Less%resistance%to%flow%"%reduced%SVR%

•  Increases%venous%return%"%increased%PL%and%CO%

•  Tissue%hypoxia%"%vasodila=on%•  Reduced%SVR%

•  Hemorrhage%"%hypovolemia%•  Reduced%PL%and%CO%

• Anemia)

Increased)OR)Decreased)

CO)

Reduced)SVR)

• MLCK%induces%vascular%smooth%muscle%contrac=on%

• MLCK%ac=vated%by%Ca2+%

•  Excita=on+Contrac=on%coupling%

• Low)iCa2+)

Reduced)

SVR)

Decreased)

CO)

•  Depressed%myocardial%contrac=lity%•  pH%<7.2%

•  Resistance%to%catecholamines%•  Severe%acidemia%

•  Peripheral%arteriolar%vasodilata=on%

• Acidosis)

Reduced)SVR)

Decreased)

CO.%

•  Prevent%if%possible%•  Heat+seeking%&%heat+conserving%behaviors%

•  Passive%surface%rewarming%•  External%covers%(i.e.:%blankets)%

•  Ac=ve%surface%rewarming%•  Warm%water%boPles,%forced%air%blankets%

•  Ac=ve%core%rewarming%•  Warm%H2O%enemas,%warmed%IVF,%warmed%pleural/peritoneal/UB/gastric%lavage%

• Therapies)K)Hypothermia)

Correct)

Hypothermia.%

•  Type%of%rewarming%depends%on%cause%&%severity%

•  Rewarm%1+2C%per%hour;%faster%rates%may%be%necessary%

• Mild%•  Warmed%blankets%

• Moderate/Severe%•  Forced%air%blankets%+%warm%IVF%+/+%warm%UB%lavage%+/+%warm%water%enemas%


Correct)

Hypothermia.%

•  Be%conscien=ous%of%thermal%injury%•  Barrier%between%pa=ent%&%external%hea=ng%device%

•  No%electric%hea=ng%blankets%

•  Hypotension%&%significant%peripheral%vasoconstric=on%raise%risk%for%thermal%injury%

•  Apply%external%heat%sources%to%chest%&%abdomen%


Correct)

Hypothermia.%

7/17/14%

6%

•  Ac=ve%core%rewarming%&%passive%surface%warming%at%the%same%=me%

•  Helps%reduce%core+to+peripheral%temperature%gradient%

•  Do%not%immerse%in%warm%water%•  Peripheral%vasodila=on%

•  Dysrhythmias%

•  Poten=a=on%of%hypovolemia%

•  Avoid%ac=ve%rewarming%once%T>98.6F%(37C)%


Correct)

Hypothermia.%

• With%effec=ve%rewarming:%•  Adrenergic%reac=vity%restored%

•  Vascular%responsiveness%improves%

•  Cau=on%using%large%volumes%of%crystalloids%

•  Hypervolemia%

•  Pulmonary%edema%

•  Conserva=ve%fluid%therapy%with%concurrent%aggressive%rewarming%


Correct)

Hypothermia.%

•  Target%normal%acid/base%status%•  pH,%HCO3,%BE,%Lactate%

•  Fluid%therapy%

•  Crystalloids%

•  Isotonic%

•  Hypertonic%

•  Colloids%

• Therapies)–)Electrolytes)&)Acid/Base)

Correct)

Electrolyte)

AbnormaliMes)

Correct))

Acid/Base)

AbnormaliMes)

•  Target%normal%iCa2+%

•  Low%

•  10%%calcium%gluconate%@%0.5+1%mL/kg%IV%

over%20+30%minutes%

•  High%

•  Avoid%iatrogenic%hypercalcemia%

•  Target%normal%K+%

•  Low%

•  KCl%@%0.1+0.5%mEq/kg/hr%IV%CRI%

•  High%

•  IVF,%insulin/dextrose,%NaHCO3%

• Therapies)–)Electrolytes)&)Acid/Base)

Correct)

Electrolyte)

AbnormaliMes)

Correct))

Acid/Base)

AbnormaliMes)

What)Type)of)Fluid)to)Give?)

•  Ensure%adequate%intravascular%volume%•  Crystalloid%–%isotonic%vs.%hypertonic%

•  Colloid%–%synthe=c%vs.%natural%

•  Ini=al%fluid%choice%depends%on:%•  Underlying%disease%process%

•  COP%

•  Electrolyte%derangements%

•  Acid+base%status%

•  Coagula=on%

•  Major%organ%func=on%

• Therapies)–)Focus)on)CO)

Provide)

Adequate)

Preload.%

7/17/14%

7%

TradiMonal)Starling)Model) Endothelial)Glycocalyx)

• Gatekeeper%•  Key%determinant%of%vascular%permeability%

• Mechanotransduc=on%•  Provides%mechanical%protec=on%from%shear%stress%to%endothelium%through%NO%produc=on%

• Microenvironment%•  Receptor%binding,%local%growth%&%repair%and%vasculoprotec=on%

Endothelial)Glycocalyx)

• Membrane+bound%proteoglycans%•  Syndecans%

• Glycosaminoglycans%(GAGs)%•  Heparin%sulfate%•  Chondroi=n%sulfate%•  Hyaluronan%•  Cell%adhesion%molecules%(CAMs)%

•  Albumin%

•  Average%thickness:%2%μm%thick%

•  Semi+permeable%to%anionic%macromolecules%

•  Impermeable%to%molecules%>70kDa%


• Occupies%substan=al%volume%of%intravascular%space%

• Onco=c%pressure%difference%across%the%glycocalyx%opposes%but%does%NOT%reverse%filtra=on%rate%•  “No%absorp=on%rule”%

Revised)Starling)Model)

• Arterioles%&%capillaries%are%non+porous%–%minimal%filtra=on%occurs%

• Venules%are%porous%–%colloid%&%fluid%enters%inters==al%space%from%intravascular%space%

Revised)Starling)Model)

High)Intravascular)Pressure)

•  Inward+directed%onco=c%pressure%gradient%%

•  High%resistance%to%flow%within%narrow%strand%gaps%of%endothelia%

Low)Intravascular)Pressure)

•  Free%&%easy%access%of%plasma%cons=tuents%toward%parenchymal%cells%

•  Highly%effec=ve%exchange%of%nutrients%&%waste%products%

•  Fluid%shiW%is%modest%if%glycocalyx%is%intact%

7/17/14%

8%


•  Increases%shedding%&%disrup=on%associated%with:%•  TNF+alpha%•  Reduc=on+oxida=on%stress%•  LPS%•  Thrombin%•  Ischemia/perfusion%•  Hyperglycemia%•  Hypervolemia%•  Hypernatremia%•  Trauma%•  Surgery%•  Synthe=c%colloids%

•  Effects%of%glycocalyx%damage:%•  Capillary%leak%•  Edema%•  Hypercoagulability%•  Inflamma=on%•  Loss%of%vascular%responsiveness%

•  PLT%aggrega=on%

Issues)with)HES)

AKI)&)

Need)for)RRT)

Coagulopathies)&))

PLT)DysfuncMon)

HES)–)AKI)ConnecMon)

•  Hyperonco=c%acute%renal%failure%•  Increased%plasma%onco=c%pressure%enough%to%oppose%hydraulic%filtra=on%at%Bowman’s%capsule%

•  Tubular%reabsorp=on%•  Tubular%swelling%"%tubular%obstruc=on%"%medullary%ischemia%

•  Dose+related%

•  Hyperviscous%urine%•  Results%in%tubular%stasis%"%tubular%obstruc=on%"%medullary%ischemia%

•  Increased%intra+abdominal%pressure%/%ACS%

•  Direct%toxicity%•  Osmo=c%nephrosis+like%lesions%–%associated%with%dysfunc=on?%

• HES)&)AKI/Need)for)RRT)• The%take+away%

• Humans%• HES%not%recommended%in%pa=ents%with%sepsis,%severe%sepsis%or%sep=c%shock%

• Animals%• No%data%documen=ng%associa=on%of%HES%with%AKI%

• May%be%prudent%to%limit%HES%use%in%pa=ents%with%pre+exis=ng%renal%injury%and/or%at+risk%for%renal%tubular%injury%

Hydroxyethylstarches)&))

PLT)DysfuncMon/Coagulopathies)

•  Implicated%in:%• Platelet%dysfunc=on%

• Coagula=on%abnormali=es%

•  In!vitro!vs.%in!vivo!"%clinical%relevance?%

7/17/14%

9%

HES)&)Coagulopathies) HES)&)PLT)DysfuncMon)

HES)binds))

GP)IIb/IIIa)receptor)

Inhibits)fibrinogen)

binding)to)receptor)

Prevents)outsideKtoK

inside)signaling)

No)PLT)upKregulaMon)

No)fibrin)meshwork)

Hydroxyethylstarches)&))

PLT)DysfuncMon/Coagulopathies)

• The%take+away%•  In!vitro!and%in!vitro!studies%have%documented%adverse%effects%on%platelet%func=on%&%coagula=on%• Higher%MW%and%DS%associated%with%more%pronounced%platelet%dysfunc=on%•  Clinical%relevance%on%platelet%dysfunc=on%&%coagula=on%not%known%• Use%with%cau=on%in%pa=ents%with%pre+exis=ng%coagula=on%abnormali=es%

How)Much)Fluid)to)Give?)

“As)much)as)they)need…and)then)not)a)drop)more”)–)Dr.)Paul)Marik))

•  Establish%endpoints%of%resuscita=on%(EOR)%•  Normal%TPR,%mm/CRT%

•  MAP%>65%mmHg,%SAP%>80+90%mmHg%

•  Improved%LOC%

•  UOP%at%least%1+2%mL/kg/hr%

•  Adequate%CVP%(5+10%cm%H20)%

•  Lactate%<2.5%mmol/L%OR%clearance%>50%%Normal%BE%(+2%–%2%mmol/L)%

•  pH%>7.32%

•  ScvO2%>68%%


Provide)

Adequate)

Preload.%

•  Target%PCV%>25+30%%•  4%blood%groups:%A,%B,%AB,%&%MIK%

•  Blood%typing%&%matching%are%vital!%

•  Type%A%blood%to%Type%B%=%possibly!fatal!

•  Type%B%blood%to%Type%A%=%mild!reacLon!but!RBC!survival!reduced%

•  pRBCs%(or!FWB/WB!if!hypoproteinemic)%

•  5+10%mL/kg/hr%in%normovolemic%pa=ents%

•  Up%to%20%mL/kg/hr%in%hypovolemic%pa=ents%

•  2+3%mL/kg/hr%in%those%with%cardiac%disease%or%

renal%failure%


Provide)

Adequate)

Preload.%

7/17/14%

10%

• Myocardial%depression%common%%

•  Echocardiography%to%see%reduced%cardiac%contrac=lity%

•  Inotropic%op=ons:%•  Dopamine%(DOP)*%

•  Dobutamine%(DOB)*%

•  Ephedrine%(EPH)%

•  Epinephrine%(EP)%

•  Norepinephrine%(NE)%

•  Phenylephrine%(PH)%


Ensure)Proper)

ContracMlity%

•  Dopamine%•  1+4%mcg/kg/min%

•  Enhanced%mesenteric%&%renal%(?)%perfusion%

•  Wohl%JS,%et%al%(J!Vet!Emerg!Crit!Care,%2007)%

•  No%difference%in%UOP,%Na+%excre=on,%HR%or%CREA%

clearance%

•  5$10'mcg/kg/min'

•  Beta'agonist'>'Alpha'agonist'effects'

•  Increased'cardiac'contrac>lity'and'HR'

•  Mild'increase'in'SVR'

•  10+20%mcg/kg/min%

•  Alpha%agonist%effects%

•  Possible%renal,%GI%and%cardiac%ischemia%


Ensure)Proper)

ContracMlity)

DOPAMINE'

•  Pascoe%PJ,%et%al%(Am!J!Vet!Res,%2006)%•  Compared%DOP,%DOB,%PH%&%EP%in%healthy%cats%anesthe=zed%with%isoflurane%

•  All%medica=ons%had%a%posi=ve%inotropic%effect%&%increased%MAP%(except%DOB)%

•  DOP%had%most%useful%effects%

•  Contrac=lity%improved%@%5%mcg/kg/min%IV%CRI%

•  10%mcg/kg/min%IV%CRI%needed%to%maintain%

MAP%>70%mmHg%


Ensure)Proper)

ContracMlity)

DOPAMINE!

•  Aramaki%Y,%et%al%(J!Vet!Med!Sci,%2002)%•  DOP%increased%HR,%BP%and%cardiac%contrac=lity%@%10%mcg/kg/min%IV%CRI%


Ensure)Proper)

ContracMlity)

DOPAMINE!

•  Pascoe%PJ,%et%al%(Am!J!Vet!Res,%2006)%•  DOB%had%greater%effect%on%contrac=lity%than%DOP%

•  MAP%increased%in%3%cats%by%20%%+%not%sta=s=cally%significant%

•  MAP%decreased%in%2%cats%@%2.5%mcg/kg/min%&%did%not%return%to%normal%@%20%mcg/kg/min%


Ensure)Proper)

ContracMlity)

DOBUTAMINE!

•  Kenakin%TP,%et%al%(Eur!J!Pharmacol,%1985)%

•  Increased%contrac=lity%without%increased%HR%or%BP%

•  Maccarone%C,%et%al%(J!Cardiovasc!Pharmacol,%1984)%

•  Bilaterally%vagotomized%cats%anesthe=zed%with%

phenobarbital%

•  Dose+dependent%increased%in%MAP%

•  Novotny%MJ,%et%al%(Adv!Exp!Med!Biol,%1996)%

•  No%increase%in%contrac=lity%in%taurine%deficient%cats%%

•  Increased%contrac=lity%with%normal%taurine%levels%


Ensure)Proper)

ContracMlity)

DOBUTAMINE!

7/17/14%

11%

•  Ephedrine%•  S=mulates%alpha,%beta+1%and%beta+2%receptors%&%mediates%NE%release%

•  Administer%as%a%bolus%or%as%CRI%

•  Bolus:%0.15+0.25%mg/kg%IV%

•  CRI:%5+10%mcg/kg/min%IV%CRI%

•  Side%effects%

•  Tachycardia,%2nd%degree%heart%block,%

bradycardia%due%to%hypertension,%VPCs%


Ensure)Proper)

ContracMlity)

EPHEDRINE'

•  Ephedrine%•  Egger%C,%et%al%(Can!Vet!J,!2009)%

•  10%cats%anesthe=zed%with%acepromazine,%

butorphanol,%ketamine%and%isoflurane%

•  Received%ephedrine%or%saline%10%minutes%prior%

to%premedica=on%

•  Systolic%BP%significantly%lower%in%saline%group%

@%10%minutes%post+premedica=on%

•  Systolic%BP%<80%mmHg%for%dura=on%of%

procedure%in%saline%group%

•  Systolic%BP%lower%than%baseline%in%ephridrine%

group%but%not%<80%mmHg%un=l%25%minutes%

post+premedica=on%


Ensure)Proper)

ContracMlity)

EPHEDRINE'

•  Epinephrine%/%Norepinephrine%•  Usually%used%as%a%last%resort%

•  0.05+3%mcg/kg/min%IV%CRI%

•  Metabolic%costs%

•  Increased%[lactate]%

•  Progressive%metabolic%acidosis%

•  Pascoe%PJ,%et%al%(Am!J!Vet!Res,%2006)%

•  Worse%than%with%DOP%and%DOB%


Ensure)Proper)

ContracMlity)

Epinephrine'/'Norepinephrine'

• When%using%inotropes:%•  Monitor%BP,%HR%and%ECG%

•  Reduce%or%discon=nue%once%BP%EOR%reached%

•  MAP%>65%mmHg%/%SAP%>80+90%mmHg%

•  Gradually%reduce%dopamine%rate%

•  Pascoe%et%al%(Am!J!Vet!Res,%2006)%–%abrupt%

discon=nua=on%may%cause%hypotension%

•  Discon=nue%CRI%if%dysrhythmias%occur%


Ensure)Proper)

ContracMlity)

•  AL%determined%by%peripheral%vascular%tone%

•  Clinical%signs%of%vasodila=on%•  Hyperemic%mucous%membranes%

•  Brisk%CRT%(<1%second)%

•  Hyperkine=c%/%“bounding”%pulses%

•  Use%vasopressors%when:%•  Adequately%volume%resuscitated%

•  Persistent%hypotension%

•  Clinical%signs%of%vasodila=on%

• Therapies)–)Focus)on)SVR)

Maintain)

Appropriate)AL)

•  Commonly%available%vasopressors:%•  Dopamine%(DOP)*%

•  Norepinephrine%(NE)*%

•  Vasopressin%(V)*%

•  Epinephrine%(EP)%

•  Phenylephrine%(PH)%

• Which%one%to%use%first?%•  Bahloul%M,%et%al%(Tunis!Med,%2012)%

•  Medico+surgical%ICU%pa=ents%with%shock%

•  Sep=c%shock%"%dopamine%(85.7%)%


Maintain)

Appropriate)AL)

7/17/14%

12%

• Which%one%to%use%first?%•  Ferguson+Myrthil%N%(Cardiol!Rev,%2012)%

•  No%clear%mortality%benefit%of%any%one%

vasopressor%over%another%

•  Physician%preference%guides%therapy%

•  NE%tends%to%be%most%preferred%in%hypotensive%

states%(including%cardiogenic%&%sep=c%shock)%


Maintain)

Appropriate)AL)

•  Dopamine%•  1+4%mcg/kg/min%

•  Enhanced%mesenteric%&%renal%(?)%perfusion%

•  Wohl%JS,%et%al%(J!Vet!Emerg!Crit!Care,%2007)%

•  No%difference%in%UOP,%Na+%excre=on,%HR%or%CREA%

clearance%


•  Beta'agonist'>'Alpha'agonist'effects'

•  Increased'cardiac'contrac>lity'and'HR'

•  Mild'increase'in'SVR'


•  Alpha'agonist'effects'

•  Possible'renal,'GI'and'cardiac'ischemia'


Maintain)

Appropriate)AL)

DOPAMINE'

•  Norepinephrine%•  Alpha+1%>%beta+1%agonist%

•  Minimal%effects%on%HR%and%CO%

•  Meier+Hellmann%A,%et%al%(Intensive!Care!Med,%

1999)%

•  Can%be%used%in%face%of%normal%or%elevated%CO%

•  BePer%improvement%of%MAP%compared%to%DOP?%

•  Karzai%W,%et%al%(Am!J!Physiol,%1995)%+%dogs%

•  Mar=n%C,%et%al%(Chest,%1993)%+%humans%


Maintain)

Appropriate)AL)

NOREPINEPHRINE'

•  Norepinephrine%•  Assess%cardiac%func=on%before%using%

•  Can%exacerbate%cardiac%insufficiency%due%to%

increased%AL%

•  Unless%using%PAC%to%monitor%CO,%LV%filling%

pressure%&%SVR,%use%DOP%1st%

•  Usually%reserved%for%unresponsive%hypotension%

•  0.05+1%mcg/kg/min%IV%CRI%


Maintain)

Appropriate)AL)

NOREPINEPHRINE'

•  Dopamine%vs.%Norepinephrine%•  Patel%GP,%et%al%(Shock,%2010)%

•  Compared%1st+line%%efficacy%of%DOP%vs.%NE%in%sep=c%shock%pa=ents%

•  DOP%28+day%mortality%=%50%%compared%to%NE%28+day%mortality%=%43%%

•  Higher%incidence%of%sinus%tachycardia%and%arrhythmias%with%DOP%

•  De%Backer%D,%et%al%(N!Eng!J!Med,%2010)%

•  Compared%1st+line%efficacy%of%DOP%vs.%NE%in%shock%pa=ents%

•  No%overall%difference%in%28+day%mortality%rate%between%DOP%and%NE%

•  Higher%28+day%mortality%rate%with%DOP%in%pa=ents%with%cardiogenic%shock%

but%not%sep=c%or%hypovolemic%shock%

•  More%arrythmic%events%in%DOP%group%

• Therapies)–)Focus)on)SVR)•  Vasopressin%

•  Vasoconstric=on%mediated%by%V1a%receptors%on%vascular%endothelium%

•  Catecholamine%receptors%may%be%dysfunc=onal%/%down+regulated%with%acidemia%

•  Modest%BE,%et%al%(Chest,%1995)%

•  Low%levels%of%endogenous%vasopressin%in%pa=ents%with%sep=c%shock%

•  Landry%DW,%et%al%(CirculaLon,%1997)%

•  Sharshar%T,%el%al%(Crit!Care!Med,%2002)%


Maintain)

Appropriate)AL)

VASOPRESSIN'

7/17/14%

13%

•  Vasopressin%•  Silverstein%DC,%et%al%(J!Vet!Emerg!Crit!Care,%2007)%

•  All%had%hypotension%despite%adequate%intravascular%volume%

•  Used%in%dogs%with%dopamine+resistant%

hypotension%&%vasodilatory%shock%

•  All%had%increases%in%MAP%with%vasopressin%

•  No%dysrhythmias%or%CVP%changes%noted%


Maintain)

Appropriate)AL)

VASOPRESSIN'

•  Vasopressin%•  Guzman%JA,%et%al%(J!Appl!Pharmacol,%2003)%

•  IV%NE%vs.%IV%V%effects%on%splanchnic%circula=on%&%

renal%perfusion%in%dogs%with%endotoxic%shock%

•  Not%catecholamine+resistant%pa=ents%

•  Splanchnic%effects%comparable%

•  More%bradycardia%with%V%

•  V%restored%renal%blood%flow%&%DO2!–!NE%did%not%


Maintain)

Appropriate)AL)

VASOPRESSIN'

•  Vasopressin%•  Minneci%PC,%et%al%(Am!J!Physiol!Heart!Circ!Physiol,%2004)%

•  Induced%Escherichia!coli%sep=c%shock%in%dogs%

•  EP%vs.%NE%vs.%V%vs.%placebo%

•  All%received%an=microbial%&%IVF%

•  NE%&%V%more%favorable%risk+benefit%profiles%

than%EP%

•  EP’s%harmful%effect%related%to%dose%

•  Only%V%restored%renal%blood%flow%

•  No%complica=ons%with%V%use%in%any%dog%


Maintain)

Appropriate)AL)

VASOPRESSIN'

•  Vasopressin%•  High%dose%therapy%associated%with:%

•  Excessive%coronary%&%splanchnic%

vasoconstric=on%

•  Hypercoagulable%states%

•  Reduced%CO%

•  Fatal%cardiac%events%

•  Skin%sloughing%

•  Galac=c%backorder…%


Maintain)

Appropriate)AL)

VASOPRESSIN'

Correct%hypothermia%

Correct%electrolytes%&%acid/base%abnormali=es%

Focus%on%CO%• PL%and%contrac=lity%

Focus%on%SVR%• AL%

• Conclusion)

QUESTIONS?

7/17/14%

14%

@VetGirlOnTheRun%

VetGirlOnTheRun%

[email protected]%

[email protected]%

Questions?

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