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C03 Critical Care Pharmacology: Vasopressors, and Inotropes Educational Objectives: 1. Provide an understanding of what inotropic agents and vaspressors are Peter Pickkers MD, PhD 4:00-5:30 Tuesday, February 14 2. Understand the various syndromes in which vasopressors and inotropes need to be used 3. Review current literature on vasopressors and inotropic agents, of both established and new agents. Content Description: Preload is the stretch of a muscle immediately prior to contraction. In the context of human pathophysiology, preload is the left ventricular end diastolic fibre length which is proportional to left ventricular end diastolic volume (LVEDV). This in turn is proportional to LVEDP. Clinically this sometimes is measured by venous pressures (JVP or CVP). The famous Starling curve relates an increase in preload to an increase in force of contraction (increasing LVEDV increases cardiac output). Afterload is the pressure developed in the myocardium wall during systole. A decrease in afterload (vasodilatation) will increase the cardiac output. and often vice versa. A positive inotropic agent will increase force of contraction independent of preload and afterload. A vasopressor agent is one that will increase vascular tone and hence increase blood pressure. It is important to conceptually differentiate these two phenomena, but in the clinical situation one agent may have both effects. Shock can be defined as inadequate tissue oxygenation. The various causes of shock have been divided into 4 categories:- hypovolaemic, distributive, cardiogenic and obstructive. (Note, clinically there may sometimes be overlap or a combination). Distributive shock is most often <strong>from</strong> sepsis. The most common use of vasopressors in ICU is in septic shock, as it is for the use of inotropic agents. Whilst there is no ideal inotropic agent, many have been used for septic shock. This holds too for vaspressor agents too, The various agents used clinically will be reviewed as will their “side effects”. It is probably safe to say most commonly dobutamine and norepinephrine are used in septic shock, but clinical data of new drugs is becoming available. Apart <strong>from</strong> the conventional agents, mechanism of action and clinical effects of vasopressin, potassium channel blockers and levosimendan will be presented. Suggested Reading: 1. De Backer D, Aldecoa C, Njimi H, Vincent JL. Dopamine versus norepinephrine in the treatment of septic shock: A meta-analysis. Crit Care Med. 2011 Oct 27. [Epub ahead of print] 2. Annane D, Vignon P, Renault A, Bollaert PE, Charpentier C, Martin C, Troché G, Ricard JD, Nitenberg G, Papazian L, Azoulay E, Bellissant E; CATS Study Group. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet. 2007 Aug 25;370(9588):676-84. 3. Landoni G, Biondi-Zoccai G, Greco M, Greco T, Bignami E, Morelli A, Guarracino F, Zangrillo A. Effects of levosimendan on mortality and hospitalization. A meta-analysis of randomized controlled studies. Crit Care Med. 2012 Feb;40(2):634-46. 4. Doorduin J, Heunks LM, Pickkers P. How can you mend a broken heart?. Crit Care Med. 2012 Feb;40(2):702-3. 5. Papp Z, Edes I, Fruhwald S, De Hert SG, Salmenperä M, Leppikangas H, Mebazaa A, Landoni G, Grossini E, Caimmi P, Morelli A, Guarracino F, Schwinger RH, Meyer S, Algotsson L, Wikström BG, Jörgensen K, Filippatos G, Parissis JT, González MJ, Parkhomenko A, Yilmaz MB, Kivikko M, Pollesello P, Follath F. Levosimendan: Molecular mechanisms and clinical implications Consensus of experts on the mechanisms of 73
action of levosimendan. Levosimendan: Molecular mechanisms and clinical implications Consensus of experts on the mechanisms of action of levosimendan. Int J Cardiol. 2011 Jul 23. [Epub ahead of print] 6. Russell JA. Bench-to-bedside review: Vasopressin in the management of septic shock. Crit Care. 2011 Aug 11;15(4):226. 7. Pickkers P, Dorresteijn MJ, Bouw MP, van der Hoeven JG, Smits P. In vivo evidence for nitric oxide-mediated calcium-activated potassium-channel activation during human endotoxemia. Circulation. 2006 Aug 1;114(5):414-21. 8. Warrillow S, Egi M, Bellomo R. Randomized, double-blind, placebo-controlled crossover pilot study of a potassium channel blocker in patients with septic shock. Crit Care Med. 2006 Apr;34(4):980-5. 74
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CRRT 2012 SEVENTEENTH INTERNATIONAL
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FACULTY DISCLOSURES CRRT 2012 Facul
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CRRT 2012 ORGANIZING COMMITTEE USA
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CRRT 2012 FACULTY Patrick Honoré,
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ACKNOWLEDGEMENTS CRRT 2012 ACKNOWLE
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PLENARY SESSIONS CRRT 2012 PROGRAM/
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WORKSHOPS CRRT 2012 PROGRAM/INDEX T
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WORKSHOPS CRRT 2012 PROGRAM/INDEX W
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POSTER ABSTRACTS C
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Page 26 and 27: NURSING FORUM LUNCHEON Communicatio
Page 28 and 29: Nutritional Support in ICU Patients
Page 30 and 31: Educational Objectives: The Endothe
Page 32 and 33: SPECIAL LECTURE Engineering Critica
Page 34 and 35: Nishimura R, Ornato JP, Page RL, Ri
Page 36 and 37: Do Vasoactive Drugs and Fluids Impr
Page 38 and 39: Blood Transfusions are Important fo
Page 40 and 41: Thinking Outside of the Box: A Nove
Page 42 and 43: Nursing Forum 2 Luncheon Benchmarki
Page 44 and 45: 4. Mori K, Lee HT, Rapoport D, Drex
Page 46 and 47: Differential Diagnosis of AKI: Can
Page 48 and 49: Myocardial Stunning and Brain Edema
Page 50 and 51: 4. Udy A, Roberts JA, Lipman J. Wha
Page 52 and 53: CRRT and ECMO: Techniques and Outco
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Page 56 and 57: Avoiding Anticoagulation for CRRT:
Page 58 and 59: Improving Outcomes from</st
Page 60 and 61: The Changing Face of AKI: Snapshots
Page 62 and 63: Alkaline Phosphatase Peter Pickkers
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Page 66 and 67: Surveillance and Early Recognition
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Page 70 and 71: A01 Assessing the Microcirculation
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Page 80 and 81: G07 Fluids and Solutions in the Cri
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Page 86 and 87: C11 Critical Care Management: Nutri
Page 88 and 89: D12 Biomarkers 2: Application in AK
Page 90 and 91: Educational Objectives: E13 Liver a
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Page 94 and 95: Educational Objectives: 1) Discuss
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