Fluid therpy

Question 1

Physical exam findings to suggest high ventricular filling pressures

Answer 1

Diffuse or dependent crackles and JVD suggest high filling pressures unless ARDS or diffuse pneumonia is present

Question 2

PE findings to suggest low ventricular filling pressures

Answer 2

Clear lung fields and flat neck veins in the setting of hypotension

Question 3

Risks of overly aggressive fluid resuscitation

Answer 3

Pulmonary edema, ileus or bowel edema and compartment syndromes

Question 4

Ways to avoid giving too much fluid

Answer 4

Frequent chest auscultation, PaO2 and CVP monitoring

Question 5

When should you consider IAP monitoring?

Answer 5

In patients requiring massive fluid resuscitation

Question 6

Vasopressor

Answer 6

A medication that has alpha-1 adrenergic activity leading to arteriole constriction, rise in SVR and arterial BP

Question 7

Inotrope

Answer 7

Medication that augments cardiac contractility and HR through beta-1 adrenergic effects

Question 8

Beta-1-adrenergic receptor

Answer 8

Increases cardiac contractility and/or HR

Question 9

Beta-2-adrenergic receptor

Answer 9

Mediates bronchodilation and arteriole dilation

Question 10

Alpha-1-adrenergic receptor

Answer 10

Mediates arteriole constriction and increases PVR

Question 11

Norepinephrine (levophed)

Answer 11

• 0.01-0.5 ug/kg/min
• DOC in septic shock.
• Potent alpha-1 vasoconstrictor
• Also has beta-1 inotropic and chronotropic effects
• Usually increases renal blood flow in patients

Question 12

Dopamine

Answer 12

• 1-20 ug/kg/min
• 1-5 ug/kg/min acts on dopamine receptor and increases urine output. No benefit to this.
• 6-10 ug/kg/min acts primarily on beta-1 receptors to increase the HR
• > 10 ug/kg/min has significant alpha-1 effects to cause vasoconstriction
• Potential AEs = arrhythmias and tachycardia

Question 13

Epinephrine

Answer 13

• 0.01-0.5 ug/kg/min
• Potent alpha-1, beta-1 and beta-2 effects
• Increases myocardial O2 consumption
• Do not use in patient with CAD

Question 14

Phenylephrine (Neo-Synephrine)

Answer 14

• 1-300 ug/min (start at 25 ug/min
• Pure alpha-1 vasoconstrictor (arterial only!)
• Best in neurogenic shock or hypotension caused by an epidural catheter

Question 15

Vasopressin

Answer 15

• Vasopressor that acts on V1 receptors to cause vasoconstriction
• Higher doses may lead to ischemic events
• May be used in hypotensive shock that is refractory to other agents but no improvement in mortality

Question 16

Dobutamine

Answer 16

• 1-20 ug/kg/min
• Acts on non-selective B adrenergic agonists
• Has inotropic effects leading to increased CO from increased stroke volume
• Use with caution because it can cause a drop in BP if hydration status inadequate

Question 17

Milrinone

Answer 17

• Phosphodiesterase inhibitor with indirect beta-1 and beta-2 effects
• Inhibits breakdown of cyclic AMP, the second messenger for catecholamines.
• Increases CO by increasing stroke volume
• Decreases after load by causing arteriole dilation
• Use with caution in hypovolemic patients!