My protocol has us using Levophed for cardiogenic shock. At 0.05-0.3mcg/kg/mim. And titration to a MAP >65. What is your thought on this course of treatment for this patient?
Michael, fantastic question! For "classical" types of heart failure norepinephrine titration to a MAP of >65 is actually a really solid protocol. In this scenario our patient has a history of dilated cardiomyopathy with a very low ejection fraction, and unfortunately this type of heart failure is a little trickier to diagnose in the field unless your patient was the absolute best historian possible, or if you had run them multiple times in the past. In cases of dilated cardiomyopathy with low EF, the ventricles become dilated without any hypertrophy occurring in the ventricular walls. Essentially this creates a giant, floppy container with severely limited contracting ability. Purely inotropic agents like dopamine and dobutamine are more effective here because these medications work by increasing cardiac contractility which causes an increase in stroke volume regardless of ventricular filling pressure (this is also one of the reasons why it is so dangerous to initiate these medications without adequate fluid resuscitation). The increase in contractility will hopefully increase the ejection fraction and raise overall cardiac output. While norepinephrine has inotropic properties, its effects tend to lean more towards vasoconstriction, so if given all possible information regarding this patient's underlying condition and if given the options of multiple vasoactive medications, dopamine and dobutamine would be the more ideal choices for this patient. You would not be wrong in using norepinephrine however, because the patient would still likely improve from the overall increase in cardiac output that you would be able to achieve. Just curious, your protocols are very very progressive, where do you practice? -Alex
Very interesting card. Any chance on doing one for atrial fibrillation with RVR? Thanks!👍👍
Tony, check out Static Cardiology Cards 22 and 33!
ruclips.net/video/_BrmIEZp8t8/видео.html
ruclips.net/video/N0ZUV-IlUBI/видео.html
My protocol has us using Levophed for cardiogenic shock. At 0.05-0.3mcg/kg/mim. And titration to a MAP >65. What is your thought on this course of treatment for this patient?
Michael, fantastic question! For "classical" types of heart failure norepinephrine titration to a MAP of >65 is actually a really solid protocol. In this scenario our patient has a history of dilated cardiomyopathy with a very low ejection fraction, and unfortunately this type of heart failure is a little trickier to diagnose in the field unless your patient was the absolute best historian possible, or if you had run them multiple times in the past. In cases of dilated cardiomyopathy with low EF, the ventricles become dilated without any hypertrophy occurring in the ventricular walls. Essentially this creates a giant, floppy container with severely limited contracting ability. Purely inotropic agents like dopamine and dobutamine are more effective here because these medications work by increasing cardiac contractility which causes an increase in stroke volume regardless of ventricular filling pressure (this is also one of the reasons why it is so dangerous to initiate these medications without adequate fluid resuscitation). The increase in contractility will hopefully increase the ejection fraction and raise overall cardiac output. While norepinephrine has inotropic properties, its effects tend to lean more towards vasoconstriction, so if given all possible information regarding this patient's underlying condition and if given the options of multiple vasoactive medications, dopamine and dobutamine would be the more ideal choices for this patient. You would not be wrong in using norepinephrine however, because the patient would still likely improve from the overall increase in cardiac output that you would be able to achieve. Just curious, your protocols are very very progressive, where do you practice? -Alex