pressors and sepsis

Hypotensive septic pts usually have a high HR already. Dopamine increases the HR. Levophed doesn't, making it the drug of choice most of the time, there is always an exception to the rule though.

Septic shock is usually related to extreme vasodilation. Levo is a strong alpha adrenergic stimulator which will cause arterial/venous constriction. Dopamine has alpha effects at high doses, but also has some pretty potent beta effects as well. The increased HR and oxygen demand are effects that are not needed in septic shock, so levo is the drug of choice.

What agility said. Dopamine will suck up oxygen that a septic patient just can't provide. Levo will cause the BP to go up without requiring an increase in oxygen consumption to make it happen.

Another point to make is that Dopamine will usually need to be run at higher doses to be effective when dealing with sepsis..as dopamine at higher doses is equivalent to Norepi, why not start with the norepi which you know will work? You'll be wasting precious time titrating low dose Dopa which won't get the desired result.

Now, another point to bring up is the increasing use of Vasopressin for sepsis. There is information out there that Vaso is actually more effective than Norepi...but it's not the gold standard yet. What you'll run in to is the idea that physician preference may play a larger role in what is your first line vasopressor than actual evidence-based medicine. I'd encourage you to do a medline search for articles on the use of vasopressin and see what your docs impressions are. I know personally, I've had good outcomes with using vasopressin.

I tried reading the data on vasopressin use for sepsis, whatever it's dosed, IIRC it's 0.04 units/min, after I had a lady on it for the first time.

The data doesn't thoroughly support its use. Most studies say "Eh, it seems to work, go for it but be cautious." I even asked our fellow and he said the data isn't super strong either.

Ditto...increased hr +increased o2 demand = cardiac overload

Part of managing septic shock is oxygen delivery vs. oxygen demand. Dopamine will increase myocardial O2 demand secondary to stimulation of beta receptors in the heart.

What meandragonbrett said...and see this:

http://www.survivingsepsis.org/Pages/default.aspx