Blog Archives

Vasopressor and Inotrope Use in Canadian Emergency Departments: Evidence Based Consensus Guidelines

1/3/2016

Thank you Dr Amit Maini for sharing this with us.

Published about a year ago in the CJEM. The article can be downloaded here and the executive summary here (both open access).

Executive Summary:

Strong Recommendations:

Cardiogenic shock patients in the ED should receive norepinephrine as the first-line vasopressor.
Norepinephrine is the first line vasopressor for use in septic shock.
Dobutamine should be used for septic shock with low cardiac output despite adequate volume resuscitation.
Epinephrine infusion is the preferred agent for anaphylactic shock that does not respond to intramuscular or intravenous bolus epinephrine.
In undifferentiated shock not responding to fluid resuscitation, norepinephrine should be the first line vasopressor.

Conditional Recommendations:

Cardiogenic shock patients in the ED should receive dobutamine if an inotrope is deemed necessary.
Routine vasopressor use in hypovolemic shock is not recommended.
Vasopressin may be indicated in hemorrhagic or hypovolemic shock if a vasopressor is deemed necessary.
In obstructive shock not responding to indicated treatment, a systemically active vasopressor should be instituted.
For patients with known or suspected hypertrophic obstructive cardiomyopathy (HOCM) or dynamic outflow obstruction, inotropic agents should be avoided. Judicious use of vasoconstrictive agents can be considered.
Vasopressin should be considered in cathecholamine refractory septic shock.
Vasopressor choice in neurogenic shock is not clear. The agent should be determined by patient characteristics and response to treatment.
Norepinephrine is the first line agent for the management of distributive shock due to hepatic failure.
Vasopressor choice in distributive shock secondary to adrenal insufficiency not responding to steroid replacement is not clear. Patient response to chosen agents should guide therapy.
In undifferentiated shock, a second vasopressor should be added if a goal MAP > 70 mmHg is not being achieved.
Short term vasopressor infusions (<1-2 hours) or boluses via properly positioned and functioning peripheral intravenous catheters are unlikely to cause local complications.
Vasopressor infusions for prolonged periods (>2-6 hours) should preferentially be administered via central venous catheters.
Inotropes can be given via peripheral catheter (short term) or central venous catheters (prolonged period) with a similarly low incidence of local complications.
The administration of vasopressors via intra-osseous lines is safe in adults.

Djogovic et al Vasopressor and Inotrope Use in Canadian Emergency Departments: Evidence Based Consensus Guidelines, CJEM 2015

Sepsis-3: new definitions and clinical criteria

28/2/2016

Click the button for a video describing the development of the new criteria:

Use a Bag-Valve Mask, Not a Non-Rebreather Mask, for Preoxygenating Before Intubation

15/2/2016

Hello all,

I would like to highlight a recently published study. Despite the small numbers (30 healthy volunteers) it probably has important implications to our practice. It is titled: "Assessment of Common Preoxygenation Strategies Outside of the Operating Room Environment” and is authored by previous Monash and Alfred Health registrar, now London HEMS FACEM, Chris Groombridge.

From the conclusions - “...the effectiveness of BVM (bag-valve-mask) preoxygenation was comparable to the anesthetic circuit, and superior to preoxygenation with NRM (non-rebreather mask). The addition of nasal cannulae oxygen, PEEP, or both, did not improve the efficacy of the BVM device”.

This does not mean you shouldn’t continue using nasal cannulae oxygen for apneic oxygenation during induction, but you should probably preoxygenate using a BVM rather than NRM.

Bellow is the abstract, and click here for the original article from Academic Emergency Medicine (still in near final draft form).

Danny

ABSTRACT

Objectives: Preoxygenation prior to intubation aims to increase the duration of safe apnea by causing denitrogenation of the functional residual capacity, replacing this volume with a reservoir of oxygen. In the operating room (OR) the criterion-standard for preoxygenation is an anesthetic circuit and well-fitting face mask, which provide a high fractional inspired oxygen concentration (FiO2). Outside of the OR, various strategies exist to provide preoxygenation. The objective was to evaluate the effectiveness of commonly used preoxygenation strategies outside of the OR environment.

Methods: This was a prospective randomized unblinded study of 30 healthy staff volunteers from a major trauma center emergency department (ED) in Sydney, Australia. The main outcome measure is fractional expired oxygen concentration (FeO2) measured after a 3 minute period of tidal volume breathing with seven different preoxygenation strategies.

Results: The mean FeO2 achieved with the anesthetic circuit was 81.0% (95% CI = 78.3% to 83.6%), bag-valve-mask (BVM) 80.1% (95% CI = 76.5% to 83.6%), BVM with nasal cannulae (NC) 74.8% (95% CI = 72.0% to 77.6%), BVM with positive end expiratory pressure valve (PEEP) 78.9% (95% CI = 75.4% to 82.3%), BVM + NC + PEEP 75.5% (95% CI = 72.2% to 78.9%), non-rebreather mask (NRM) 51.6% (95% CI = 48.8% to 54.4%), and NRM + NC 57.1% (95% CI = 52.9% to 61.2%). Preoxygenation efficacy with BVM strategies was significantly greater than NRM strategies (p < 0.01), and non-inferior to the anesthetic circuit.

Conclusions: In healthy volunteers, the effectiveness of BVM preoxygenation was comparable to the anesthetic circuit (criterion standard), and superior to preoxygenation with NRM. The addition of nasal cannulae oxygen, PEEP, or both, did not improve the efficacy of the BVM device.

Great tip: using tissue glue around eyes

13/2/2016

Have you ever glued an eye shut? Thanks to Simon Craig for alerting us to some useful resources to prevent this sticky situation!