Best Practices in the Management of Vasodilatory Shock: A Call for Collaboration

Consider steroids when/if a second vasopressor is required
Emergency departments (EDs) try their best to manage various complex issues that arise in triaging and managing variety of patients
The ED is not an ideal place for an intensive care unit (ICU) patient

Published studies demonstrate that the quality of care and outcomes of care in the ICU is related to the effectiveness of the team
Lower nurse/patient ratio in the ICU
Efficient interface with specialty consultants
Ready access to respiratory therapy
No question that excellence in critical care is based on team-building
Nursing staff have, in many ways, specialized knowledge that is not possessed by physician staff
Same thing is true for respiratory therapy
Each member of the team contributes important knowledge

Systems Involved in Restoring Effective BP[8]
Body normally has 3 systems that it uses to maintain the adequacy of perfusion
Catecholamine pathway is the fight or flight response we get that manifests in the setting of disease and injury
The second is the arginine vasopressin pathway
Vasopressin, also known asantidiuretic hormone (ADH) is originates in the posterior pituitary, prompts fluid retention, the kidneys, and promotes vasoconstriction at the arterial level
The third arm for maintaining blood pressures is the renin-angiotensin-aldosterone system (RAAS)
RAAS frequently addressed and managed in the setting of chronic hypertension
Angiotensinogen production in the liver
Renin produced in the kidneys
Renin acts as a catalyst for a reaction that converts angiotensinogen into angiotensin I, which is a precursor hormone that is converted to an active hormone called angiotensin II by angiotensin-converting enzyme (ACE) in the lungs
Angiotensin II has multiple effects; the pertinent one here is vasoconstriction
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock[1]

Vasopressors for the Treatment of Critically Ill Patients: Evidence for Norepinephrine[6]
For years, many experts viewed norepinephrine as the first-line agent
Evidence based published by De Backer et al in 2010
Large European randomized controlled trial: no difference in mortality in the use of dopamine vs norepinephrine
Higher rate of complications associated with dopamine: higher tachycardia, tachyarrhythmia
That is why norepinephrine was the favorite of most intensivists for years and ED physicians
Vasopressors for the Treatment of Septic Shock[9]

MAP Goal
We have convincing intraoperative and postoperative data, and in postoperative critically ill patients, that show a drop in mean arterial pressure (MAP) is associated with myocardial injury and mortality
Surviving sepsis guidelines support MAP more than 65 mm Hg
Important context is the patient's baseline BP
Patients with cardiomyopathy or hepatic insufficiency patients may have a chronically low BP
Targeting a MAP of 65 mm Hg may be a futile effort
Prevention of Complications[1,10,11]
Team-based approach contributes to prevention of complications
Proper use of sedation, prophylactic measures like deep venous thrombosis prophylaxis, elevating the head of the bed, are nursing measures
Interventions are also initiated by other members of the team, including pharmacists and respiratory therapists, among others