Vasopressors and
Inotropes in Canadian
Emergency Departments
Dennis Djogovic MD, FRCPC
Financial Disclosures
 None to declare
 ER docs treat shock
 There are no evidence based guidelines to assist in
which pressor/trope to use in shock
 VICE has created a document to address that
 CAEP standards committee
 CJEM
VICE squad
 Shavaun MacDonald
Rob Green
 Andrea Wensel
Osama Loubani
 James Lee
Patrick Archambault
 Janeva Kircher
Simon Bordeleau
 Katherine Smith
Adam Szulewski
 Jon Davidow
Sara Gray
 Dennis Djogovic
Jean Marc Benoit
David Messenger
Dan Howes
What is Shock?
What are the types of shock?
 Cardiogenic
 Obstructive
 Distributive
 Hypovolemic
What are vasopressors?
 Systemic vasoconstriction
 Pulmonary vasoconstriction
 Increase Mean Arterial Pressure (MAP)
What are inotropes?
 Agents that increase cardiac output
 Increase inotropy
 Increase chronotropy
 Decrease afterload
Inotropes
Vasopressors
Intra aortic Balloon Pump
Phenylephrine
Dobutamine
Ephedrine
Isoproteronol
Norepinephrine
Epinephrine
Dopamine
Milrinone
Nitroprusside
Digoxin
Different shock types need
different managment
 Guidelines based on different shock types
Research methodology
(only one slide!)
 AGREE II
 PICO questions
 Section authors/literature review
 GRADE
 Quality of evidence
 Strength of recommendation
 Delphi consensus process
 88 530 articles identified
 1040 articles in focused article list
 113 articles used for grading purposes
 7 clinical questions
 18 recommendations
 5 strong
 13 conditional
Quality of Evidence
 A= High Level of evidence
 Good RCT
 B= Moderate
 Poor RCT, well done observational series
 C= low
 Poor observational series
 D= very low
 Case series, expert opinion
Strength of Recommendation
 Balance desirable and undesirable effects
 Quality of evidence
 Values and preferences
 costs
Strength of Recommendation
 Strong
 Conditional
 70% of votes needed for “Strong” recommendation
Question 1: For ED patients in shock,
what are the side effects of
vasopressors and inotropes?
 Dopamine increases the risk of tachyarrhythmia
compared to norepinephrine. (Grade A).
 Dopamine use in septic shock increases mortality
compared to norepinephrine (Grade B).
 Vasopressin as a first line vasopressor may be
associated with cellular ischemia and skin necrosis,
particularly when combined with sustained moderate
to high dose infusions of norepinephrine. (Grade C).
 Epinephrine increases metabolic abnormalities
compared to norepinephrine. (Grade A).
 Epinephrine increases metabolic abnormalities
compared to norepinephrine-dobutamine in
cardiogenic shock without acute cardiac ischemia.
(Grade B).
Question 2: Which vasopressors and
inotropes should be used in the treatment
of ED patients with cardiogenic shock?
 Recommendation: Cardiogenic shock patients in the
ED should receive norepinephrine as the first-line
vasopressor. (Strong)
Question 2: Which vasopressors and
inotropes should be used in the treatment
of ED patients with cardiogenic shock?
 Recommendation: Cardiogenic shock patients in the
ED should receive dobutamine if an inotrope is
deemed necessary. (Conditional)
Question 3: Which vasopressors and
inotropes should be used in the treatment
of ED patients with hypovolemic shock?
 Recommendation: Routine vasopressor use in
hypovolemic shock is not recommended.
(Conditional)
 Recommendation: Vasopressin may be indicated in
hemorrhagic or hypovolemic shock if a vasopressor is
deemed necessary. (Conditional)
Question 4: Which vasopressors and
inotropes should be used in ED
patients with obstructive shock?
 Recommendation: In obstructive shock not
responding to indicated treatment, a systemically
active vasopressor should be instituted. (Conditional)
Question 4: Which vasopressors and
inotropes should be used in ED
patients with obstructive shock?
 Recommendation: 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.
(Conditional)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
 Recommendations: Norepinephrine is the first line
vasopressor for use in septic shock. (Strong)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
 Recommendation: Vasopressin should be considered
in catecholamine refractory septic shock.
(Conditional)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
 Recommendation: Dobutamine should be used for
septic shock with low cardiac output despite
adequate volume resuscitation. (Strong)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
 Recommendation: Vasopressor choice in neurogenic
shock is not clear. The agent should be determined
by patient characteristics and response to treatment.
(Conditional)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
Recommendation: Norepinephrine is the first line agent
for the management of distributive shock due to
hepatic failure. (Conditional)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
 Recommendation: Epinephrine infusion is the
preferred agent for anaphylactic shock that does not
respond to intramuscular or intravenous bolus
epinephrine. (Strong)
Question 5: Which vasopressors and
inotropes should be used in ED
patients with distributive shock?
 Recommendation: 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. (Conditional)
Question 6: Which vasopressors and
inotropes should be used in ED
patients with undifferentiated shock?
 Recommendation: In undifferentiated shock not
responding to fluid resuscitation, norepinephrine
should be the first-line vasopressor. (Strong)
Question 6: Which vasopressors and
inotropes should be used in ED
patients with undifferentiated shock?
 Recommendation: In undifferentiated shock, a second
vasopressor should be added if a goal MAP>70mmHg is
not being achieved. (Conditional)
Question 7: How should vasopressors
and inotropes be administered to ED
patients?
 Recommendation: Short term vasopressor infusions
(<1-2 hours) or boluses via properly positioned and
functioning peripheral intravenous catheters are
unlikely to cause local complications. (Conditional)
Question 7: How should vasopressors
and inotropes be administered to ED
patients?
 Recommendation: Vasopressor infusions for prolonged
periods (>2-6 hours) should preferentially be
administered via central venous catheters.
(Conditional)
Question 7: How should vasopressors
and inotropes be administered to ED
patients?
 Recommendation: Inotropes can be given via
peripheral catheter (short term) or central venous
catheters (prolonged period) with a similarly low
incidence of local complications. (Conditional)
Question 7: How should vasopressors
and inotropes be administered to ED
patients?
 Recommendation: The administration of vasopressors
via intra-osseous lines is safe in adults. (Conditional)
Question 7: How should vasopressors
and inotropes be administered to ED
patients?
In summary
 Identify the type of shock
 To determine the type of treatment
 Norepi > dopamine
 Cross your fingers!