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7/17/14%
1%
Tackling)Feline)Hypotension)
Christopher)G.)Byers,)DVM,)DACVECC,)DACVIM)(SAIM))
MidWest)Veterinary)Specialty)Hospital)
Omaha,)Nebraska)USA)
@CriMcalCareDVM)
www.criMcalcaredvm.com!
VetGirl…on)the)RUN!)
• The%tech+saavy%way%to%get%CE%credit!%
• A%subscrip=on+based%podcast%and%webinar%service%offering%veterinary%RACE+approved%CE%
SubscripMon)plans)
• VetGirl%Standard:%50+60%podcasts/year%%
• $99/year%%
• 4%hours%of%RACE+CE%%
• VetGirl%ELITE:%50+60%podcasts/year%plus!20%hours%of%webinars!%
• $199/year%
• 20+%hours%of%RACE+CE%
iTunes)Download!!!)
Find us on social media Blogs)and)Social)Media)
hPp://www.pinterest.com/vetgirlontherun/%
@vetgirlontherun%
7/17/14%
2%
LogisMcs:)CE)CerMficates)
! No%need%to%raise%your%hand!%
! Type%in%ques=ons%
! Emailed%to%you%48%hours%aWer%the%webinar%
! Ac=ve%par=cipa=on%=%no%quiz%
! Watching%video%later,%must%complete%quiz%
! ELITE%members%only%
! Email%/%contact%with%ANY%ques=ons%
Call)in)from)Smart)Phone!)
Christopher%Byers,%DVM,%%DACVECC,%DACVIM%(SAIM)%
MidWest%Veterinary%%Specialty%Hospital%
PresentaMon)Layout)
How%do%we%define%hypotension%in%cats?%
What%factor(s)%contribute%to%hypotension%in%cats?%
How%do%we%maintain%AL?%
Defini=on%
Causes%
Cardiac%Output%
SVR%
How%do%we%maximize%PL%and%contrac=lity?%
• Hypotension!
• MAP%<60%mmHg%/%SAP%<80+90%mmHg%
• Preload!(PL)!
• End+volumetric%pressure%that%stretches%the%right%or%leW%
ventricle%
• Clinically%measured%by%ventricular%end+diastolic%volume%
• A5erload!(AL)!
• Load%against%which%the%heart%contracts%to%eject%blood%
• Clinically%the%pressure%heart%chambers%must%generate%to%
eject%blood%
• DefiniMons)
CO)=)HR)x)SV)
BP)=)CO)x)SVR.%
• Stroke!Volume!(SV)!• Volume%of%blood%pumped%from%one%ventricle%
with%each%heart%beat%
• Influenced%by%PL,%AL%&%contrac=lity%
• Systemic!Vascular!Resistance!(SVR)!• Resistance%to%flow%that%must%be%overcome%to%push%blood%through%the%circulatory%system%
• Cardiac!Output!(CO)!• Volume%of%blood%being%pumped%by%the%heart%in%one%minute%
• DefiniMons)
SVR)=)(MAP)–)
CVP))/)CO)
SV)=)EDV)K)ESV))
7/17/14%
3%
• Early!Goal@Directed!Therapy!(EGDT)!• Rivers%EP,%et%al%(N!Eng!J!Med,%2001)%
• 16%%reduc=on%in%overall%mortality%and%12%%reduc=on%in%60+day%mortality%
• With%hypotension%OR%elevated%lactate:%
• Crystalloid%bolus%(20+40%mL/kg)%or%colloid%equivalent%
• Target%CVP%8+12%mmHg%
• Apply%vasoac=ve%medica=ons%if%MAP%<65%mmHg%or%>90%mmHg%
• If%ScvO2%<70%,%give%pRBCs%to%maintain%PCV%>30%%
• Consider%mechanical%ven=la=on%to%reduce%pa=ent%oxygen%demand%
• DefiniMons)
EGDT bundle, adapted from Rivers EP, et al (N Eng J Med, 2001)
• Early!Goal@Directed!Therapy!(EGDT)!• Why%do%we%care?%
• Rivers%EP,%et%al%(Curr!Opin!Anesthesiol,%2008)%
• Reduced%sepsis+related%mortality%by%46%%
• Shorr%AF,%et%al%(Crit!Care!Med,%2007)%
• Reduced%hospital%length+of+stay%by%5%days%
• Reduced%hospital%charges%by%$5,%882%per%pa=ent%
• Veterinary%evidence+based%medicine%lacking,%but…%
• Prire%J%(J!Vet!Emerg!Crit!Care,%2006)%
• Butler%A%(Vet!Clin!North!Am!Sm!Anim,%2011)%
• DefiniMons)
• Shock%Triad%• “Triad%of%Death”%
• Each%point%of%triangle%will%cause%or%contribute%to%severity%of%the%others%
• DefiniMons)
Hypotension%
Hypothermia%Bradycardia%
• Adrenal%medullary%catecholamine%secre=on%
• Local%release%of%NE%from%post+ganglionic%nerve%fibers%
Increased)
sympatheMc)
output)
Skin,%kidneys%and%viscera%most%affected%
VasoconstricMon)
• DefiniMons)
• Manifesta=on%of%1%or%more:%• Hypovolemia%
• Decreased%SVR%
• Cardiac%dysfunc=on%yielding%reduced%CO%
• Many%issues%contribute%• Bradycardia%
• Hypothermia%
• Anemia%
• Low%iCa2+%
• Acidosis%
• Hypotension)Causes)
Reduced)CO)
Hypovolemia.%
Decreased)
SVR.%
7/17/14%
4%
• HR%<120%bpm%
• Schwartz%PJ,%et%al%(Circ!Res,%1973)%• Inadequate%arterial%stretch%triggers%simultaneous%sympathe=c%&%vagal%firing%
• Reason%for%blunted%tachycardia%response?%
• Oncken%A,%et%al%(unpublished!data)%• Series%of%77%hypotensive%cats%(SAP%<80%mmHg)%
• All%had%normal%or%slow%heart%rates%
• Bradycardia)
Reduced)CO)
• CO%=%HR%x%SV%
• General%causes:%• SA%node%doesn’t%fire%
• Impulse%conduc=on%blocked%at%AV%node%
• Idioventricular%rhythms%
• Need%ECG%to%determine%type%of%bradyarrhythmia%
• Bradyarrhythmia)
Reduced)CO)
Blunted)HR)
response)
Reduced)
peripheral)
perfusion)
Hypothermia)
• Alpha+1%receptors%(cutaneous)%• Responsiveness%declines%with%decreased%core%temperatures%
• Decreased%receptor%affinity%
• Vasodila=on%
• Beta+1%adrenergic%receptors%• Desensi=zed%
• LV%contrac=lity%reduced%
• Hypothermia)
Reduced)CO)
Decreased)
SVR)
• Abnormal%rhythms%• J%waves,%AF,%VF%
• Hypothermia)
Reduced)CO)
Decreased)
SVR)
• Kishi%K,%et%al%(Anesth!Analg,%2009)%• Experimental%cat%model;%20%cats%
• Anesthe=zed%with%pentobarbital%
• Normothermia%vs.%hypothermia%(32C)%
• Evaluated%response%of%pial%arterioles%to%hemorrhagic%hypotension%
• Hypothermia%impaired%autoregulatory%vasodila=on%
• Hypothermia)
Reduced)CO)
Decreased)
SVR)
• CaO2%=%(1.34%x%Hgb%x%SaO2)%+%(0.0031%x%PaO2)%
• No%issue%with%dissolved%O2%"%concern%is%Hgb%satura=on%
• DO2%=%CO%x%CaO2%
• Compensatory%mechanism%• Increase%CO%
• Increase%blood%oxygen%extrac=on%
• Anemia)
7/17/14%
5%
• Due%to%low%CaO2,%SV%and%HR%(thus%CO)%increase%
• Normovolemic%anemia%
• [RBC]%is%major%determinant%of%viscosity%• Less%resistance%to%flow%"%reduced%SVR%
• Increases%venous%return%"%increased%PL%and%CO%
• Tissue%hypoxia%"%vasodila=on%• Reduced%SVR%
• Hemorrhage%"%hypovolemia%• Reduced%PL%and%CO%
• Anemia)
Increased)OR)Decreased)
CO)
Reduced)SVR)
• MLCK%induces%vascular%smooth%muscle%contrac=on%
• MLCK%ac=vated%by%Ca2+%
• Excita=on+Contrac=on%coupling%
• Low)iCa2+)
Reduced)
SVR)
Decreased)
CO)
• Depressed%myocardial%contrac=lity%• pH%<7.2%
• Resistance%to%catecholamines%• Severe%acidemia%
• Peripheral%arteriolar%vasodilata=on%
• Acidosis)
Reduced)SVR)
Decreased)
CO.%
• Prevent%if%possible%• Heat+seeking%&%heat+conserving%behaviors%
• Passive%surface%rewarming%• External%covers%(i.e.:%blankets)%
• Ac=ve%surface%rewarming%• Warm%water%boPles,%forced%air%blankets%
• Ac=ve%core%rewarming%• Warm%H2O%enemas,%warmed%IVF,%warmed%pleural/peritoneal/UB/gastric%lavage%
• Therapies)K)Hypothermia)
Correct)
Hypothermia.%
• Type%of%rewarming%depends%on%cause%&%severity%
• Rewarm%1+2C%per%hour;%faster%rates%may%be%necessary%
• Mild%• Warmed%blankets%
• Moderate/Severe%• Forced%air%blankets%+%warm%IVF%+/+%warm%UB%lavage%+/+%warm%water%enemas%
• Therapies)K)Hypothermia)
Correct)
Hypothermia.%
• Be%conscien=ous%of%thermal%injury%• Barrier%between%pa=ent%&%external%hea=ng%device%
• No%electric%hea=ng%blankets%
• Hypotension%&%significant%peripheral%vasoconstric=on%raise%risk%for%thermal%injury%
• Apply%external%heat%sources%to%chest%&%abdomen%
• Therapies)K)Hypothermia)
Correct)
Hypothermia.%
7/17/14%
6%
• Ac=ve%core%rewarming%&%passive%surface%warming%at%the%same%=me%
• Helps%reduce%core+to+peripheral%temperature%gradient%
• Do%not%immerse%in%warm%water%• Peripheral%vasodila=on%
• Dysrhythmias%
• Poten=a=on%of%hypovolemia%
• Avoid%ac=ve%rewarming%once%T>98.6F%(37C)%
• Therapies)K)Hypothermia)
Correct)
Hypothermia.%
• With%effec=ve%rewarming:%• Adrenergic%reac=vity%restored%
• Vascular%responsiveness%improves%
• Cau=on%using%large%volumes%of%crystalloids%
• Hypervolemia%
• Pulmonary%edema%
• Conserva=ve%fluid%therapy%with%concurrent%aggressive%rewarming%
• Therapies)K)Hypothermia)
Correct)
Hypothermia.%
• Target%normal%acid/base%status%• pH,%HCO3,%BE,%Lactate%
• Fluid%therapy%
• Crystalloids%
• Isotonic%
• Hypertonic%
• Colloids%
• Therapies)–)Electrolytes)&)Acid/Base)
Correct)
Electrolyte)
AbnormaliMes)
Correct))
Acid/Base)
AbnormaliMes)
• Target%normal%iCa2+%
• Low%
• 10%%calcium%gluconate%@%0.5+1%mL/kg%IV%
over%20+30%minutes%
• High%
• Avoid%iatrogenic%hypercalcemia%
• Target%normal%K+%
• Low%
• KCl%@%0.1+0.5%mEq/kg/hr%IV%CRI%
• High%
• IVF,%insulin/dextrose,%NaHCO3%
• Therapies)–)Electrolytes)&)Acid/Base)
Correct)
Electrolyte)
AbnormaliMes)
Correct))
Acid/Base)
AbnormaliMes)
What)Type)of)Fluid)to)Give?)
• Ensure%adequate%intravascular%volume%• Crystalloid%–%isotonic%vs.%hypertonic%
• Colloid%–%synthe=c%vs.%natural%
• Ini=al%fluid%choice%depends%on:%• Underlying%disease%process%
• COP%
• Electrolyte%derangements%
• Acid+base%status%
• Coagula=on%
• Major%organ%func=on%
• Therapies)–)Focus)on)CO)
Provide)
Adequate)
Preload.%
7/17/14%
7%
TradiMonal)Starling)Model) Endothelial)Glycocalyx)
• Gatekeeper%• Key%determinant%of%vascular%permeability%
• Mechanotransduc=on%• Provides%mechanical%protec=on%from%shear%stress%to%endothelium%through%NO%produc=on%
• Microenvironment%• Receptor%binding,%local%growth%&%repair%and%vasculoprotec=on%
Endothelial)Glycocalyx)
• Membrane+bound%proteoglycans%• Syndecans%
• Glycosaminoglycans%(GAGs)%• Heparin%sulfate%• Chondroi=n%sulfate%• Hyaluronan%• Cell%adhesion%molecules%(CAMs)%
• Albumin%
• Average%thickness:%2%μm%thick%
• Semi+permeable%to%anionic%macromolecules%
• Impermeable%to%molecules%>70kDa%
Endothelial)Glycocalyx)
• Occupies%substan=al%volume%of%intravascular%space%
• Onco=c%pressure%difference%across%the%glycocalyx%opposes%but%does%NOT%reverse%filtra=on%rate%• “No%absorp=on%rule”%
Revised)Starling)Model)
• Arterioles%&%capillaries%are%non+porous%–%minimal%filtra=on%occurs%
• Venules%are%porous%–%colloid%&%fluid%enters%inters==al%space%from%intravascular%space%
Revised)Starling)Model)
High)Intravascular)Pressure)
• Inward+directed%onco=c%pressure%gradient%%
• High%resistance%to%flow%within%narrow%strand%gaps%of%endothelia%
Low)Intravascular)Pressure)
• Free%&%easy%access%of%plasma%cons=tuents%toward%parenchymal%cells%
• Highly%effec=ve%exchange%of%nutrients%&%waste%products%
• Fluid%shiW%is%modest%if%glycocalyx%is%intact%
7/17/14%
8%
Endothelial)Glycocalyx)
• Increases%shedding%&%disrup=on%associated%with:%• TNF+alpha%• Reduc=on+oxida=on%stress%• LPS%• Thrombin%• Ischemia/perfusion%• Hyperglycemia%• Hypervolemia%• Hypernatremia%• Trauma%• Surgery%• Synthe=c%colloids%
• Effects%of%glycocalyx%damage:%• Capillary%leak%• Edema%• Hypercoagulability%• Inflamma=on%• Loss%of%vascular%responsiveness%
• PLT%aggrega=on%
Issues)with)HES)
AKI)&)
Need)for)RRT)
Coagulopathies)&))
PLT)DysfuncMon)
HES)–)AKI)ConnecMon)
• Hyperonco=c%acute%renal%failure%• Increased%plasma%onco=c%pressure%enough%to%oppose%hydraulic%filtra=on%at%Bowman’s%capsule%
• Tubular%reabsorp=on%• Tubular%swelling%"%tubular%obstruc=on%"%medullary%ischemia%
• Dose+related%
• Hyperviscous%urine%• Results%in%tubular%stasis%"%tubular%obstruc=on%"%medullary%ischemia%
• Increased%intra+abdominal%pressure%/%ACS%
• Direct%toxicity%• Osmo=c%nephrosis+like%lesions%–%associated%with%dysfunc=on?%
• HES)&)AKI/Need)for)RRT)• The%take+away%
• Humans%• HES%not%recommended%in%pa=ents%with%sepsis,%severe%sepsis%or%sep=c%shock%
• Animals%• No%data%documen=ng%associa=on%of%HES%with%AKI%
• May%be%prudent%to%limit%HES%use%in%pa=ents%with%pre+exis=ng%renal%injury%and/or%at+risk%for%renal%tubular%injury%
Hydroxyethylstarches)&))
PLT)DysfuncMon/Coagulopathies)
• Implicated%in:%• Platelet%dysfunc=on%
• Coagula=on%abnormali=es%
• In!vitro!vs.%in!vivo!"%clinical%relevance?%
7/17/14%
9%
HES)&)Coagulopathies) HES)&)PLT)DysfuncMon)
HES)binds))
GP)IIb/IIIa)receptor)
Inhibits)fibrinogen)
binding)to)receptor)
Prevents)outsideKtoK
inside)signaling)
No)PLT)upKregulaMon)
No)fibrin)meshwork)
Hydroxyethylstarches)&))
PLT)DysfuncMon/Coagulopathies)
• The%take+away%• In!vitro!and%in!vitro!studies%have%documented%adverse%effects%on%platelet%func=on%&%coagula=on%• Higher%MW%and%DS%associated%with%more%pronounced%platelet%dysfunc=on%• Clinical%relevance%on%platelet%dysfunc=on%&%coagula=on%not%known%• Use%with%cau=on%in%pa=ents%with%pre+exis=ng%coagula=on%abnormali=es%
How)Much)Fluid)to)Give?)
“As)much)as)they)need…and)then)not)a)drop)more”)–)Dr.)Paul)Marik))
• Establish%endpoints%of%resuscita=on%(EOR)%• Normal%TPR,%mm/CRT%
• MAP%>65%mmHg,%SAP%>80+90%mmHg%
• Improved%LOC%
• UOP%at%least%1+2%mL/kg/hr%
• Adequate%CVP%(5+10%cm%H20)%
• Lactate%<2.5%mmol/L%OR%clearance%>50%%Normal%BE%(+2%–%2%mmol/L)%
• pH%>7.32%
• ScvO2%>68%%
• Therapies)–)Focus)on)CO)
Provide)
Adequate)
Preload.%
• Target%PCV%>25+30%%• 4%blood%groups:%A,%B,%AB,%&%MIK%
• Blood%typing%&%matching%are%vital!%
• Type%A%blood%to%Type%B%=%possibly!fatal!
• Type%B%blood%to%Type%A%=%mild!reacLon!but!RBC!survival!reduced%
• pRBCs%(or!FWB/WB!if!hypoproteinemic)%
• 5+10%mL/kg/hr%in%normovolemic%pa=ents%
• Up%to%20%mL/kg/hr%in%hypovolemic%pa=ents%
• 2+3%mL/kg/hr%in%those%with%cardiac%disease%or%
renal%failure%
• Therapies)–)Focus)on)CO)
Provide)
Adequate)
Preload.%
7/17/14%
10%
• Myocardial%depression%common%%
• Echocardiography%to%see%reduced%cardiac%contrac=lity%
• Inotropic%op=ons:%• Dopamine%(DOP)*%
• Dobutamine%(DOB)*%
• Ephedrine%(EPH)%
• Epinephrine%(EP)%
• Norepinephrine%(NE)%
• Phenylephrine%(PH)%
• Therapies)–)Focus)on)CO)
Ensure)Proper)
ContracMlity%
• Dopamine%• 1+4%mcg/kg/min%
• Enhanced%mesenteric%&%renal%(?)%perfusion%
• Wohl%JS,%et%al%(J!Vet!Emerg!Crit!Care,%2007)%
• No%difference%in%UOP,%Na+%excre=on,%HR%or%CREA%
clearance%
• 5$10'mcg/kg/min'
• Beta'agonist'>'Alpha'agonist'effects'
• Increased'cardiac'contrac>lity'and'HR'
• Mild'increase'in'SVR'
• 10+20%mcg/kg/min%
• Alpha%agonist%effects%
• Possible%renal,%GI%and%cardiac%ischemia%
• Therapies)–)Focus)on)CO)
Ensure)Proper)
ContracMlity)
DOPAMINE'
• Pascoe%PJ,%et%al%(Am!J!Vet!Res,%2006)%• Compared%DOP,%DOB,%PH%&%EP%in%healthy%cats%anesthe=zed%with%isoflurane%
• All%medica=ons%had%a%posi=ve%inotropic%effect%&%increased%MAP%(except%DOB)%
• DOP%had%most%useful%effects%
• Contrac=lity%improved%@%5%mcg/kg/min%IV%CRI%
• 10%mcg/kg/min%IV%CRI%needed%to%maintain%
MAP%>70%mmHg%
• Therapies)–)Focus)on)CO)
Ensure)Proper)
ContracMlity)
DOPAMINE!
• Aramaki%Y,%et%al%(J!Vet!Med!Sci,%2002)%• DOP%increased%HR,%BP%and%cardiac%contrac=lity%@%10%mcg/kg/min%IV%CRI%
• Therapies)–)Focus)on)CO)
Ensure)Proper)
ContracMlity)
DOPAMINE!
• Pascoe%PJ,%et%al%(Am!J!Vet!Res,%2006)%• DOB%had%greater%effect%on%contrac=lity%than%DOP%
• MAP%increased%in%3%cats%by%20%%+%not%sta=s=cally%significant%
• MAP%decreased%in%2%cats%@%2.5%mcg/kg/min%&%did%not%return%to%normal%@%20%mcg/kg/min%
• Therapies)–)Focus)on)CO)
Ensure)Proper)
ContracMlity)
DOBUTAMINE!
• Kenakin%TP,%et%al%(Eur!J!Pharmacol,%1985)%
• Increased%contrac=lity%without%increased%HR%or%BP%
• Maccarone%C,%et%al%(J!Cardiovasc!Pharmacol,%1984)%
• Bilaterally%vagotomized%cats%anesthe=zed%with%
phenobarbital%
• Dose+dependent%increased%in%MAP%
• Novotny%MJ,%et%al%(Adv!Exp!Med!Biol,%1996)%
• No%increase%in%contrac=lity%in%taurine%deficient%cats%%
• Increased%contrac=lity%with%normal%taurine%levels%
• Therapies)–)Focus)on)CO)
Ensure)Proper)
ContracMlity)
DOBUTAMINE!
7/17/14%
11%
• Ephedrine%• S=mulates%alpha,%beta+1%and%beta+2%receptors%&%mediates%NE%release%
• Administer%as%a%bolus%or%as%CRI%
• Bolus:%0.15+0.25%mg/kg%IV%
• CRI:%5+10%mcg/kg/min%IV%CRI%
• Side%effects%
• Tachycardia,%2nd%degree%heart%block,%
bradycardia%due%to%hypertension,%VPCs%
• Therapies)–)Focus)on)CO)
Ensure)Proper)
ContracMlity)
EPHEDRINE'
• Ephedrine%• Egger%C,%et%al%(Can!Vet!J,!2009)%
• 10%cats%anesthe=zed%with%acepromazine,%
butorphanol,%ketamine%and%isoflurane%
• Received%ephedrine%or%saline%10%minutes%prior%
to%premedica=on%
• Systolic%BP%significantly%lower%in%saline%group%
@%10%minutes%post+premedica=on%
• Systolic%BP%<80%mmHg%for%dura=on%of%
procedure%in%saline%group%
• Systolic%BP%lower%than%baseline%in%ephridrine%
group%but%not%<80%mmHg%un=l%25%minutes%
post+premedica=on%
• Therapies)–)Focus)on)CO)
Ensure)Proper)
ContracMlity)
EPHEDRINE'
• Epinephrine%/%Norepinephrine%• Usually%used%as%a%last%resort%
• 0.05+3%mcg/kg/min%IV%CRI%
• Metabolic%costs%
• Increased%[lactate]%
• Progressive%metabolic%acidosis%
• Pascoe%PJ,%et%al%(Am!J!Vet!Res,%2006)%
• Worse%than%with%DOP%and%DOB%
• Therapies)–)Focus)on)CO)
Ensure)Proper)
ContracMlity)
Epinephrine'/'Norepinephrine'
• When%using%inotropes:%• Monitor%BP,%HR%and%ECG%
• Reduce%or%discon=nue%once%BP%EOR%reached%
• MAP%>65%mmHg%/%SAP%>80+90%mmHg%
• Gradually%reduce%dopamine%rate%
• Pascoe%et%al%(Am!J!Vet!Res,%2006)%–%abrupt%
discon=nua=on%may%cause%hypotension%
• Discon=nue%CRI%if%dysrhythmias%occur%
• Therapies)–)Focus)on)CO)
Ensure)Proper)
ContracMlity)
• AL%determined%by%peripheral%vascular%tone%
• Clinical%signs%of%vasodila=on%• Hyperemic%mucous%membranes%
• Brisk%CRT%(<1%second)%
• Hyperkine=c%/%“bounding”%pulses%
• Use%vasopressors%when:%• Adequately%volume%resuscitated%
• Persistent%hypotension%
• Clinical%signs%of%vasodila=on%
• Therapies)–)Focus)on)SVR)
Maintain)
Appropriate)AL)
• Commonly%available%vasopressors:%• Dopamine%(DOP)*%
• Norepinephrine%(NE)*%
• Vasopressin%(V)*%
• Epinephrine%(EP)%
• Phenylephrine%(PH)%
• Which%one%to%use%first?%• Bahloul%M,%et%al%(Tunis!Med,%2012)%
• Medico+surgical%ICU%pa=ents%with%shock%
• Sep=c%shock%"%dopamine%(85.7%)%
• Therapies)–)Focus)on)SVR)
Maintain)
Appropriate)AL)
7/17/14%
12%
• Which%one%to%use%first?%• Ferguson+Myrthil%N%(Cardiol!Rev,%2012)%
• No%clear%mortality%benefit%of%any%one%
vasopressor%over%another%
• Physician%preference%guides%therapy%
• NE%tends%to%be%most%preferred%in%hypotensive%
states%(including%cardiogenic%&%sep=c%shock)%
• Therapies)–)Focus)on)SVR)
Maintain)
Appropriate)AL)
• Dopamine%• 1+4%mcg/kg/min%
• Enhanced%mesenteric%&%renal%(?)%perfusion%
• Wohl%JS,%et%al%(J!Vet!Emerg!Crit!Care,%2007)%
• No%difference%in%UOP,%Na+%excre=on,%HR%or%CREA%
clearance%
• 5$10'mcg/kg/min'
• Beta'agonist'>'Alpha'agonist'effects'
• Increased'cardiac'contrac>lity'and'HR'
• Mild'increase'in'SVR'
• 10$20'mcg/kg/min'
• Alpha'agonist'effects'
• Possible'renal,'GI'and'cardiac'ischemia'
• Therapies)–)Focus)on)SVR)
Maintain)
Appropriate)AL)
DOPAMINE'
• Norepinephrine%• Alpha+1%>%beta+1%agonist%
• Minimal%effects%on%HR%and%CO%
• Meier+Hellmann%A,%et%al%(Intensive!Care!Med,%
1999)%
• Can%be%used%in%face%of%normal%or%elevated%CO%
• BePer%improvement%of%MAP%compared%to%DOP?%
• Karzai%W,%et%al%(Am!J!Physiol,%1995)%+%dogs%
• Mar=n%C,%et%al%(Chest,%1993)%+%humans%
• Therapies)–)Focus)on)SVR)
Maintain)
Appropriate)AL)
NOREPINEPHRINE'
• Norepinephrine%• Assess%cardiac%func=on%before%using%
• Can%exacerbate%cardiac%insufficiency%due%to%
increased%AL%
• Unless%using%PAC%to%monitor%CO,%LV%filling%
pressure%&%SVR,%use%DOP%1st%
• Usually%reserved%for%unresponsive%hypotension%
• 0.05+1%mcg/kg/min%IV%CRI%
• Therapies)–)Focus)on)SVR)
Maintain)
Appropriate)AL)
NOREPINEPHRINE'
• Dopamine%vs.%Norepinephrine%• Patel%GP,%et%al%(Shock,%2010)%
• Compared%1st+line%%efficacy%of%DOP%vs.%NE%in%sep=c%shock%pa=ents%
• DOP%28+day%mortality%=%50%%compared%to%NE%28+day%mortality%=%43%%
• Higher%incidence%of%sinus%tachycardia%and%arrhythmias%with%DOP%
• De%Backer%D,%et%al%(N!Eng!J!Med,%2010)%
• Compared%1st+line%efficacy%of%DOP%vs.%NE%in%shock%pa=ents%
• No%overall%difference%in%28+day%mortality%rate%between%DOP%and%NE%
• Higher%28+day%mortality%rate%with%DOP%in%pa=ents%with%cardiogenic%shock%
but%not%sep=c%or%hypovolemic%shock%
• More%arrythmic%events%in%DOP%group%
• Therapies)–)Focus)on)SVR)• Vasopressin%
• Vasoconstric=on%mediated%by%V1a%receptors%on%vascular%endothelium%
• Catecholamine%receptors%may%be%dysfunc=onal%/%down+regulated%with%acidemia%
• Modest%BE,%et%al%(Chest,%1995)%
• Low%levels%of%endogenous%vasopressin%in%pa=ents%with%sep=c%shock%
• Landry%DW,%et%al%(CirculaLon,%1997)%
• Sharshar%T,%el%al%(Crit!Care!Med,%2002)%
• Therapies)–)Focus)on)SVR)
Maintain)
Appropriate)AL)
VASOPRESSIN'
7/17/14%
13%
• Vasopressin%• Silverstein%DC,%et%al%(J!Vet!Emerg!Crit!Care,%2007)%
• All%had%hypotension%despite%adequate%intravascular%volume%
• Used%in%dogs%with%dopamine+resistant%
hypotension%&%vasodilatory%shock%
• All%had%increases%in%MAP%with%vasopressin%
• No%dysrhythmias%or%CVP%changes%noted%
• Therapies)–)Focus)on)SVR)
Maintain)
Appropriate)AL)
VASOPRESSIN'
• Vasopressin%• Guzman%JA,%et%al%(J!Appl!Pharmacol,%2003)%
• IV%NE%vs.%IV%V%effects%on%splanchnic%circula=on%&%
renal%perfusion%in%dogs%with%endotoxic%shock%
• Not%catecholamine+resistant%pa=ents%
• Splanchnic%effects%comparable%
• More%bradycardia%with%V%
• V%restored%renal%blood%flow%&%DO2!–!NE%did%not%
• Therapies)–)Focus)on)SVR)
Maintain)
Appropriate)AL)
VASOPRESSIN'
• Vasopressin%• Minneci%PC,%et%al%(Am!J!Physiol!Heart!Circ!Physiol,%2004)%
• Induced%Escherichia!coli%sep=c%shock%in%dogs%
• EP%vs.%NE%vs.%V%vs.%placebo%
• All%received%an=microbial%&%IVF%
• NE%&%V%more%favorable%risk+benefit%profiles%
than%EP%
• EP’s%harmful%effect%related%to%dose%
• Only%V%restored%renal%blood%flow%
• No%complica=ons%with%V%use%in%any%dog%
• Therapies)–)Focus)on)SVR)
Maintain)
Appropriate)AL)
VASOPRESSIN'
• Vasopressin%• High%dose%therapy%associated%with:%
• Excessive%coronary%&%splanchnic%
vasoconstric=on%
• Hypercoagulable%states%
• Reduced%CO%
• Fatal%cardiac%events%
• Skin%sloughing%
• Galac=c%backorder…%
• Therapies)–)Focus)on)SVR)
Maintain)
Appropriate)AL)
VASOPRESSIN'
Correct%hypothermia%
Correct%electrolytes%&%acid/base%abnormali=es%
Focus%on%CO%• PL%and%contrac=lity%
Focus%on%SVR%• AL%
• Conclusion)
QUESTIONS?
7/17/14%
14%
@VetGirlOnTheRun%
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