Vasopressor in Septic Shock, Semarang 0ct 2011

7/27/2019 Vasopressor in Septic Shock, Semarang 0ct 2011

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Vasoactive agent inseptic shock patients

dr samsirun halim SpPD KIC

PIT PAPDI Semarang 8 October 2011


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outline discussionintroduction definition septic shock hemodynamic change during septic shock type, indication and target vasopressor

guideline and evidence

conclusion

conclusion


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introduction

Septic shock is a medical emergency that is associate with mortality rate of40-70%

Prompt recognition and institution of effective therapy is required for optimaloutcome when the shock state persists after adequate fluid resuscitation , vasopresssortherapy is required to improve and maintain adequate tissue/organ perfusion

in attempt to improve survival and prevent the development of mod and mof With vasopressor is the best choice in septic shock is debatable.


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definition septic shock

ACCP/SCCM consensus confererence comitte 1992........ sepsis-induced hypotension( SBP < 90 mmHg or areduction of "40 mmHg from baseline ) despite adequatefluid resuscitationalong with the presence of perfusionabnormalitiesthat may include but are not limited to lactic

acidosis, oliguria, or an acute alteration in mental status

Dellinger RP, Crit Care Med 2003;31;946-55


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Hemodynamic change in septis chock

A. normal

B. pre fluid resuscitation



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hemodynamic change during septic shock

B. prefluid resuscitation

C. post fluid resuscitation



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Septic shock .. A melting pot of shock etiologiesDellinger RP, Crit Care Med 2003;31;946-55


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mechanism action of catecolamin andeffect of stimulating receptor

vasopressor = raise BP

inotropic = raise cardiac output

!adrenergic = promoting vasoconstrition

"1= increasing HR and myocardial contractility

"2 = peripher vasodilatation

#= vasodilation mesenteric dan renalOvergaard CB, Circulation 2008;118;1047-56


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effects of vasoactive catecholamine Hollenberg SM, Crit Care Clin 2009;25;781-802


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dopamine recommended as the initial drug of choice by many clinicians it increases bothmyocardial contractility and SVR via !and "receptors May help maintain splanchnic circulation , urine output and renal function via

dopa receptor action

1-3 mcg/kg/min dopa receptor3-10 mcg/kg/min "receptor >10 mcg/kg/min!receptor

increases HR, can cause tachyarrytmias may also increase pcwp via pulmonary artery vasoconstriction Hollenberg SM, Crit Care Clin 2009;25;781-802


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norepinephrine

potent!adrenergic agonist, less "agonist effect

MAP $by vasoconstrition, CO and SV $10-15% > potent than dopamine and > effective reversinghypotension

Hollenberg SM, Crit Care Clin 2009;25;781-802


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Phenylephrine

selective!1-adrenergic agonistBP$by vasoconstriction

rapid onset, short duration, primary vascular effect -->actractive agent in management septic shock

concern reduce COHollenberg SM, Crit Care Clin 2009;25;781-802


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epinefrine

potent!-adrenergic and "adrenergic

MAP$by $CO and $SVR $DO2 but $O2 consumption $lactacte level%regional blood flow --> splanchnic perfusion



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vasopressin peptide hormon, synthesized hypothalamus, store in the

pituitary glandreleased response to %blood volume, intravasculer volume,$plasma osmolality

constrict VSM directly via V1 receptor

$response of vasculature to cathecolamin

inhibit NO production by VSM



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Type, indication, doses, mechanism of action, major side effect ofcatecolamine

Overgaard CB, Circulation 2008;118;1047-56


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Type, indication, doses, mechanism of action, major side effect ofcatecolamine

Overgaard CB, Circulation 2008;118;1047-56


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Perfusion Goals in Patients with Septic Shock

HemodynamicsPCWP 10-20 mmHg MAP >60 mmHg CI > 3 L/min/m2

Organ perfusion

CNS - improved sensorium Skin - warm, well perfused Renal - UOP > 1cc/kg/hr O2 delivery adequacy

SpO2 > 95% - Lactate < 2 mM/L

Hgb >10 gm/dl


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Effects of perfusion pressure on tissue perfusion in septic shock

LeDoux, Astiz ME, et all Crit Care Med 2000;28;2729-32


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guideline and evidence


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NE or dopamine for the treatment of hyperdynamic septic shock Martin C, Papazian L, Perrin G. Chest 1993,103:1826-31

32 patients hyperdynamic septic shock following fluid administration

Patients received either Dopa ( 2,5-25 mcg/kg/mint) or NE (0,5-5mcg/kg/

mnt) with the goals of SVRI > 1100 dyne/m2, MAP >80mmHg, CI >4 L/min/m2, DO2 >550 ml/min/m2 dab VO2 >150mL/min/m2

Dopa achieved goal only 5/16 ( 31%) vs 15/16 (93%) NE

10 of 11 not respond DOPA respond to NE

no deleterious effect of NE on urine output , but study only 6 houres


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Comparison of Dopamine and NE in the treatment of Shockde Becker D, Biston P, Devriendt J, NEJM 2010;362:779-789

RCT 1679 pts: Dopa 858, NE 821

Dopa -20ug/kg/, NE - 0,19ug/kg/ + Epinefrin/vasopresin

outcome 1st : 28 d mortality, 2nd : number days w.o organ support andoccurence adverse events RESULTS :

NO difference in mortality DOPA 52,5% vs NE 48,5% DOPA more arytmogenic 24,1% vs 12,4%


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Does dopamine administration in shock influence outcome ?Results of Sepsis Occurrence in Acutely Ill Patients (SOAP) Study Sakr Y, Fleinhart K, Vincent JL. Crit Care Med 2006,34, 589-597

cohort, multicenter, observtional study, 3147 pts 33,6% shock----> 14,7% septic shock dopa 35,4%, non dopa 64,6%

mortality dopa in ICU 42,9%vs35% p.02

mortality hospital 48,9% vs 41,7% p=0.1

suggest dopamine administration maybe associated withincreases mortality rates in shock


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NE plus Dobutamine vs epinephrine alone for management of septicshock : a randomised trial Annane D,et all Lancet 2007. 370 ; 676-84

RCT multicentre 330 pts Epi 161 vs NE + dobu 169 ---> MAP 70 mmHG 1st outcome 28 days mortality

RESULT

mortality E (40%) vs NE + dobu (34%) p=0,31

there is no evidence in efficacy and safety between epinephrine aloneand NE plus dobutamine for the management of septic shock


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Low dose dopamine in patients with early renal dysfunction.A placebo -controlled randomised trial (ANZICS)Bellomo R, Chapman M et al. Lancet 2000;356:2139-43

328 pts randomised placebo - low dose dopamin ( 2ug/kg/)

No protective effect on renal function or other outcome wasfound


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Effects of dopamine, NE and Epinephrine on theSplanchnic Circulation in Septic Shock

Figure 2, page 1665, reproduced with permission from De Backer D, Creteur J, Silva E,

Vincent JL. Effects of dopamine, norepinephrine, and epinephrine on the splanchnic

circulation in septic shock: Which is best? Crit Care Med2003; 31:1659-1667


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Epinephrine

Levy et al.Crit Care Med 1997;25 :1649-53 found that the addition of dobutamine 5 mcg/kg/min to epinephrine infusion in 20 septic patients hadno significant effect on HR, mAP,CI,SVR,DO2 and VO2but improved gastric mucosal perfusion based ongastric intramucosal pCO2 and pH measurement


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phenylephrine

Reinelt et al. Crit Care Med 1999,27 : 325-331

reported reduced splanchnic blood flow and oxygendelivery in six septic shock patients treated withphenylephrine compared with NE


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Circulating vasopressin levels during septic shock

Figure 2, page 1755 reproduced with permission from Sharshar T,

Blanchard A, Paillard M, et al. Circulating vasopressin levels in septic

shock. Crit Care Med2003; 31:1752-1758


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Vasopressin compared to NE in septic shock : Is Vasopressin more effective ?Macias L, Varon J, Fromm RE,Crit Care & Shock 2004:7:39-41

vasopressin at a dose sufficient to substitute for

norepinephrin in the treatment of septic shock not appear tooffer any benefit over norepinephrin

the routine administration of vasopressin alone as avasopressor agent in septic shock requires more clinicalresearch trial.


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Vasopressin vs NE infusion in patients with septic shockRussel JA, Walley KR, et al. NEJM 2008;358:877-87

RCT 778 pts, Vasopresin (0.01-0.03 U/min) vs NE 5-15mcg/min )

no differences in adverse events or survival rates

less severe septic shock ( NE < 15mcg/) mortallity 26.5% vs35,7 % p .05

low doses vasopressin does not reduce mortality rates


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Conclusion

Mortality in septic shock still high Vasopressor is used to increase BP to improve perfusion

prevent the mod and mof Dopamine and NE is the first choice although dopamine hasmore arrytmogenic

Epinefrine and vasopressin is the second choice becausereduced the splancnic perfusion


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thank you


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Vasopressor in Septic Shock, Semarang 0ct 2011