Start Peripheral Vasopressors Early in Shock!

It has been dogmatically believed that prolonged infusion of any vasopressor mandates placement of a central line.  However, available evidence doesn’t support this.

  1. Diluted solutions of all catecholamines are safe (except Vasopressin) to be administered peripherally via a well functioning 18-20G IV or larger in forearm (no hand/wrist/AC) .
  2. No old IVs (>72 hrs)
  3. Know how to treat extravasation
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The Recovery Trial: Effect of Dexamethasone in Hospitalized Patients with COVID-19 – Preliminary Report

The findings of this well done randomized controlled trial indicate that in patients with COVID-19 pneumonia, that dexamethasone improves 28d mortality compared to placebo in patients requiring invasive mechanical ventilation (IMV) (NNT = 8.5) and those patients requiring oxygen therapy (NNT = 29).  There was no benefit to patients not requiring oxygenation support and even a signal for harm.  It is important to remember this is a preprint, preliminary report, which is better than a press release. At this time, in patients requiring any oxygen therapy, HFNC, NIV, IMV, or ECMO I would recommend dexamethasone until further evidence disproves this benefit.

NSAIDS increase risk of Heart Attacks

A cohort of 446 763 individuals including 61 460 with acute myocardial infarction was acquired. Taking any dose of NSAIDs for one week, one month or more than a month was associated with an increased risk of myocardial infarction. With use for one to seven days, the probability of increased myocardial infarction risk (posterior probability of odds ratio >1.0) was 92% for celecoxib, 97% for ibuprofen, and 99% for diclofenac, naproxen, and rofecoxib. The corresponding odds ratios (95% credible intervals) were 1.24 (0.91 to 1.82) for celecoxib, 1.48 (1.00 to 2.26) for ibuprofen, 1.50 (1.06 to 2.04) for diclofenac, 1.53 (1.07 to 2.33) for naproxen, and 1.58 (1.07 to 2.17) for rofecoxib. Greater risk of myocardial infarction was documented for the higher dose of NSAIDs. With use for longer than one month, risks did not appear to exceed those associated with shorter durations.

Local Anaesthesia Toxicity (LAST)

  • The key in managing LAST is prevention. Know your dose, know your maximum dose, always aspirate prior to injection and ask patient about symptoms
  • Lidocaine toxicity cardiovascular complications are typically preceded by neurological signs/symptoms. If these develop, stop administration, place patient on monitor and ready your antidote
  • Bupivacaine toxicity can be sudden and catastrophic. If you are using the drug, undershoot your max dose and know where your antidote is
  • Intralipid has been shown to be effective in LAST. Administer the drug anytime there are signs of hemodynamic compromise

 

Rapid Sequence Intubation Medications

Induction Agents

Medication Weight-Based Dosing Time to Onset of Action Adverse Effects/

Contraindications

Etomidate 0.3 mg/kg <1 minute May cause clinically insignificant adrenal suppression.
Ketamine 1-2 mg/kg 1-3 minutes May increase blood pressure. May cause hypersalivation.
Propofol 2 mg/kg <1 minute May cause hypotension. Cardiac depressant. Contraindicated in egg/soybean allergy
Midazolam 0.3 mg/kg 1-5 minutes May cause hypotension

Paralytics

Medication Weight-Based Dosing Time to Onset of Action Adverse Effects/

Contraindications

Succinylcholine 1.5 – 2.0 mg/kg 45-60 seconds Bradycardia. Malignant hyperthermia. Hyperkalemia.
Rocuronium 1.2 mg/kg 45-60 seconds
Vecuronium 0.1 mg/kg 2-4 minutes Questionable RSI utility when rocuronium available

Post-Intubation Sedation

Medication Weight-Based Dosing Notes
Midazolam 0.04-0.2 mg/kg/hr Short duration, but with long-term use has long half-life. Often used with fentanyl
Propofol 5-80 mcg/kg/min Propofol Infusion Syndrome with long term use: monitor TG, amylase/lipase
Dexmedetomidine 0.2-0.7 mcg/kg/hr
Ketamine 0.5-1 mg/kg/hr May decrease bronchospasm
Fentanyl 1-2 mcg/kg bolus25-250 mcg/hr

 

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