Vasopressors
What is the difference between Beta 1 and Beta 2 receptors?
Beta 1: act on heart to increase heart rate and contractility
Beta 2: act on bronchial and vascular tissue
What is the typical SBP goal for post operative code aortas?
SBP < 120
What is the cardiac output equation?
CO = HR x SV
What is determinant of whether a patient is CSU vs ACLS?
if the patient has had cardiac surgery, the patient is ACLS
*not all patients may be resternotomy elegible
What part of stroke volume do inotropes directly affect?
contractility
Why would we avoid neosynephrine in our cardiac patients?
Neo is a significant amount of fluid which can overload our already high preload in most of our cardiac patients
What is the typical bolus dose for Amio?
150 mg/100mL over 10 minutes
What are the components of Stroke Volume, and describe them.
Preload: amount of blood in the ventricles at the end of diastole
Afterload: pressure required to push blood into the arteries
Contractility: ventricles ability to squeeze
What is the ACLS loading dose for amiodarone?
300 mg IVP
What is the main AE of milrinone?
hypotension; providers may consider decreasing milrinone dose or increasing epi usage with patients who are severely hypotensive
Why do we have to decrease the dose of angiotensin II after 4 hours?
The half life is very short, which leads to quick titration properties with short-lasting effects. It is also pro-inflammatory and pro-thrombolytic, which increases risk for cytokine releases and thrombolytic events. The dose of 80 is significantly less effective after the first four hours of initiation.
This is your patient:
MAP 45, CI 4.8, SVR 420, CVP 9
Gtts: Levo 20, Vaso 0.06
What are your thoughts and what do you assume is your next action?
This patient is in vasoplegic shock; Normal SVR 800-1200; low SVR indicative of vasodilation and poor perfusion; anticipate giving cyanokit/methylene blue
What is an AE of Cardene we see in our patients, and how does it occur?
V:Q mismatch (shunting); occurs due to vasoconstriction in pulmonary vasculature
Does directly increasing cardiac output help clear a lactic (aka... jumping to initiation of a inotrope)?
Not always.
Figuring out the reason behind the lactic level is key...
is the patient hypoxic? is the issue regional perfusion rather than global perfusion? is there an obstructive cause? is the patient volume responsive?
If there is poor cardiac preload or myocardial dysfunction, then helping cardiac output is appropriate.
What is the MOA of nitric oxide?
vasodilator the pulmonary vasculature; can be used in thoracic patients to increase oxygenation, can decrease PVR to decrease RV workload
Which receptors do Angiotensin II act on, and what is the MOA?
Ang II Acts on the RAAS system, increases aldosterone and causes systemic vasoconstriction, water reabsorption, and sodium reuptake.
Your post op AVR patient two hours out of the OR suddenly Bradys down to 28 with a BP of 60/35.
Your patient is still intubated and sedated. Back up wires are unplugged, but your box is set to VVI 50/5/0.8 capt @ 1. What do you do next?
Pace them!! They're in a CHB!!
Plug your wires in and crank up the rate to stabilize their BP. If your wires don't work, make sure you have pads on and you can transcutaneously pace this patient.
Your patient is on the following medications:
Cardene 12.5, Milrinone 0.375
The day shift nurse says that they started the day on NC. Your patient is now on HiFlo 60 L/60%. What are you concerned about, and what is your next action?
Concerned for shunting; if patient is able to tolerate PO medications, attempt to manage with oral antihypertensives; utilize PRNs (such as hydral); look for other causes of the hypertension --> is your patient in pain? are they agitated?
Your patient goes into unstable AF RVR 170s. They are intubated and sedated, and their MAPS start to rapidly drop. What is your next action step, and what do you anticipate for this patient?
1. Put pads on patient & Call charge nurse, get resident/fellow in room
2. cardiovert due to the instability of the patient
3. amio bolus and drip initiation to prevent unstable AF RVR again
Your patient's post op TTE shows significant Biventricular dysfunction. Currently you are on epi 5, milrinone 0.25, levo 4. Gas is as follows:
PO2 55 (on 80% FiO2), Lactic 5.
What is the next anticipated action, and what is the MOA with heart patients?
inhaled Nitric oxide, indirect inotropic effects in which it decreases the PVR to decrease the workload of the RV
You come on shift and your patient is on the following:
Vaso 0.02, Levo 8, Ang II 20
Current VS:
HR 120 ST, BP 95/48 MAP 54
In what order would you increase your pressor titration and why?
1- Ang, 2- Vaso, 3- Levo
This patient is already having an increase in HR d/t compensation for a decrease in MAP. Ang II has a quicker half-life than vaso, and doesn't have AE of tachyarrhythmias like levo does. You still have wiggle room to increase your vaso, but it will take longer to see results.
Your patient is POD 0 from an AVR and CABG x1. Here is the presentation:
HR 110, MAP 60, PAP 46/24, CVP flat 24, CI 0.9, CO 2.8, SVO2 on draw 47, lactic 6.4, UOP 19 x 3 hrs, pt weighs 87 kg.
Day shift has given 2L Albumin, 2 U blood, and 1 Cryo. Current drips are: Vaso 0.04, Levo 9, Epi 1, Milrinone 0.125, Prop, fent, insulin, and a tko. What do you anticipate the team ordering to improve this clinical picture, and why do you anticipate it?
It is anticipated that you increase your epi dose. Why?
Pt is demonstrating signs of contractility issues; they have enough in the tank (REDP 24, LEDP 24), but it's not going really anywhere (increasing lactic, decreased UOP, decreased CI/SV02).
What is the indication for giving a patient methylene blue or cyanokit?
Vasoplegia
Given fluid, pressors, and increased inotropy, but the patient isn't circulating enough (isn't responding to interventions).
Your patient goes into pulseless VT. They're still in their resternotomy window. Walk through the process using CSU-ACLS.
3x stacked shocks
CPR
Amio bolus (per provider)
Prepare for resternotomy
Which inotrope is used in the PTE protocol and why?
dopamine; used to maintain a CI of 0.8-2.5