Troponin leak and pressor of choice.

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    Long story, semi short. 60 some yr old guy with a hx of cabg x 2 and chole admitted for syncopal episodes at an OSH. Patient was over there for a month runs into aki requiring dialysis and cvvh. Kidneys recover, liver fails - ercp x 2. Pt trached and finally sent to us for further management. Was sedated with Ativan up until 1 day before tx, trached and receiving tpn. Guy has intermittent runs of vtach, send full of labs. Troponin = 6.40, who knows if it was even checked at the OSH. They weren't checking his ammonia levels. Initially on norepinephrine at 10, sicu wants vaso and wean norepinephrine... I leave him w vaso on and Levo at 6. What is the pressor of choice for a troponin and guy requiring pressors for maps > 60???
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    Not sure why there's a second discussion posting on this, but here's my take (after reading previous posts): not sure there's a "presssor of choice" in a situation like this. The team is biting the bullet on a patient like this because most other sane options have been exhausted. I recent literature (NEJM
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    ...2010, DeBacker,et al) there has been a benefit of norepinephrine shown (over dopamine) for cardiogenic shock in terms of tachycardia and dysrhythmias. That said, this person was in dire straits to begin with. I recently attended a "cardiac cath lab grand rounds" where we discussed the transfer of patients such as this (being as I work at a large tertiary referral center)' and the cardiac surgeons and ECMO specialists said, generally, the earlier, the better, with patients like this. The decision must be made, early on, what the goals of care are. If the patient is insistent on all possible therapies, then put them on ECMO and hope for organs. If they (or their surrogate decision-maker) do not want ECMO or transplantation, then provide comfort care. Ideally, the accepting physician can sort through this before transfer so that an unnecessary transition does not have to take place, but many times this can't happen until the physician lays eyes on the patient.
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    Full reference for norepinephrine vs. dopamine: NEJM 362(9): 779-89, 2010 MAR 4. DeBacker, D., et al.
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    Also, this is more like a troponin "flood" than "leak". No matter what your renal function, a trop of 6.4 isn't good. Even if it's "I" vs. "T", 6.4 is substantial. Especially given the patient's history.


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