Shock

Start Peripheral Vasopressors Early in Shock!

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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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Surviving Sepsis Guidelines 2021: Recommendations and Best Practice Statements

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  • The recommendation for an initial fluid bolus of 30 mL/kg was downgraded from a strong recommendation to a weak recommendation, based on the low quality of evidence. However, resuscitation should start immediately.
  • Balanced crystalloid solution (e.g., lactated Ringer’s solution) should be used (rather than normal saline) for resuscitation.
  • Administration of vasopressors should be initiated via peripheral access, as opposed to waiting for placement of central venous access.
  • Patients with ongoing vasopressor requirements should receive intravenous corticosteroids (this recommendation was strengthened); however, administration of intravenous vitamin C is explicitly not recommended.

Where did the IV fluid go…

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DID YOU KNOW: In managing shock, for every liter of normal saline given, only 180mls remains intravascular (your normal adult intravascular volume is approx. 5L). So in hypovolaemic patients…give loads of fluids…for blood loss, give blood early, the best natural colloid.