What do you do when presented with a hypotensive patient resistant to IV fluids? Maybe throw some steroids at ’em but more likely you start dopamine. This is our go-to drug of choice as a pressor. However recent literature has shown it to be falling out of favor (ie, septic shock). So what should we use? Norepinephrine and phenylephrine.
Why do we use dopamine? Speaking from a doctor’s perspective, it’s familiarity. We know how to use it. However it may have more arryhthmogenic effects (in cardiogenic shock). There are drugs which are just as effective and probably more so… shouldn’t we get learn to use something new… or in this case, something old…?
* NOREPINEPHRINE 1 MICROgrams/min IV and titrate as high as 30 MICROgrams/min
Yes, some of you may remember this little fellow by his other name, “leave-em-dead,” but that’s a bit of a misnomer. I believe that name arose from the fact that if you were reaching for this drug, the patient wasn’t doing so well.
Goals of early goal directed therapy in sepsis requires quick restoration of perfusion to tissues. When fluids don’t cut it, vasopressors are needed to increase cardiac output and oxygenation. Norepi may be a more potent vasopressor than dopamine.
Hopefully this should go in through a central line, but what if you don’t got one? Well anesthesiologists commonly push pressors through a peripheral IV. GASP! Yes, a peripheral. Phenylephrine works well for this. This is called “push dose pressors.”
* PHENYLEPHRINE 50 MICROgrams IV push (with flush)
You should hopefully see an improvement in blood pressure in a minute or two, and it only lasts about 5 minutes.
So next time we have a code together and I ask for “push dose phenylephrine” don’t look at me funny. Instead
- grab a vial of phenylephrine (10 mg in 1 mL) and
- inject it into a 100 mL bag of saline
- now you have 100 mcg/mL.
- Put some in a 3 cc syringe.
- To give a 50 mcg dose, give 1/2 a cc.
What do you think?
* De Backer D, et al (SOAP II Investigators) Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM. March 4, 2010; 362(9): 779-89.
* EM-RAP: May 2010, Scott Weingard, MD and Mel Herbert, MD.