Category:Vasopressors: Difference between revisions
Category page
More actions
Create canonical category-page article (history-first) |
Rewrite per canonical category-page spec (history-first article) |
||
| Line 7: | Line 7: | ||
The most recent vasopressor approval is the recombinant human angiotensin II (Giapreza, La Jolla Pharmaceutical, 2017), studied in the ATHOS-3 trial of catecholamine-resistant vasodilatory shock and used as a third-line agent in selected patients with profound vasoplegia.<ref name="athos2017">Khanna A, English SW, Wang XS, Ham K, Tumlin J, Szerlip H, Busse LW, Altaweel L, Albertson TE, Mackey C, et al. Angiotensin II for the treatment of vasodilatory shock. ''New England Journal of Medicine''. 2017 Aug 3;377(5):419-430. PMID 28528561.</ref> The clinical use of angiotensin II in shock remains, as of the mid-2020s, niche but mechanistically distinct from the catecholamines, and a small body of evidence suggests it may be particularly useful in shock complicating cardiac surgery and in acute-on-chronic kidney injury with vasoplegia. | The most recent vasopressor approval is the recombinant human angiotensin II (Giapreza, La Jolla Pharmaceutical, 2017), studied in the ATHOS-3 trial of catecholamine-resistant vasodilatory shock and used as a third-line agent in selected patients with profound vasoplegia.<ref name="athos2017">Khanna A, English SW, Wang XS, Ham K, Tumlin J, Szerlip H, Busse LW, Altaweel L, Albertson TE, Mackey C, et al. Angiotensin II for the treatment of vasodilatory shock. ''New England Journal of Medicine''. 2017 Aug 3;377(5):419-430. PMID 28528561.</ref> The clinical use of angiotensin II in shock remains, as of the mid-2020s, niche but mechanistically distinct from the catecholamines, and a small body of evidence suggests it may be particularly useful in shock complicating cardiac surgery and in acute-on-chronic kidney injury with vasoplegia. | ||
The other vasopressor agents fill more specific niches. Intravenous phenylephrine, an alpha-1 selective agonist, is used by anaesthetists for the transient hypotension of spinal or epidural anaesthesia; the lack of beta-1 inotropic effect makes it useful where reflex tachycardia is to be avoided (aortic stenosis, tetralogy of Fallot, hypertrophic cardiomyopathy). Oral midodrine (an alpha-1 agonist | The other vasopressor agents fill more specific niches. Intravenous phenylephrine, an alpha-1 selective agonist, is used by anaesthetists for the transient hypotension of spinal or epidural anaesthesia; the lack of beta-1 inotropic effect makes it useful where reflex tachycardia is to be avoided (aortic stenosis, tetralogy of Fallot, hypertrophic cardiomyopathy). Oral midodrine (an alpha-1 agonist metabolically activated to desglymidodrine) is used for chronic orthostatic hypotension in autonomic failure. Methylene blue, originally an antimalarial and a methemoglobinemia antidote, is used off-label in selected catecholamine-refractory vasoplegic shock through inhibition of soluble guanylate cyclase and nitric oxide synthase. The intravenous calcium-channel antagonist reversal protocols use [[Calcium|calcium]] gluconate, glucagon, insulin-glucose, and intravenous lipid emulsion in addition to the standard catecholamine vasopressors. | ||
The clinical management of a vasopressor infusion is, like that of many intensive-care medicines, as much about technique as about dose. Central-venous access is required for sustained infusion to avoid extravasation injury; arterial-line monitoring is required for titration; the choice of agent and the rate of escalation are guided by the clinical context (sepsis: norepinephrine first, vasopressin second, angiotensin II or epinephrine third; cardiogenic shock with inadequate cardiac output: dobutamine first, epinephrine or milrinone second; anaphylaxis: intramuscular epinephrine first, intravenous epinephrine and pressors as needed; neurogenic shock with bradycardia: norepinephrine with chronotropic support). | The clinical management of a vasopressor infusion is, like that of many intensive-care medicines, as much about technique as about dose. Central-venous access is required for sustained infusion to avoid extravasation injury; arterial-line monitoring is required for titration; the choice of agent and the rate of escalation are guided by the clinical context (sepsis: norepinephrine first, vasopressin second, angiotensin II or epinephrine third; cardiogenic shock with inadequate cardiac output: dobutamine first, epinephrine or milrinone second; anaphylaxis: intramuscular epinephrine first, intravenous epinephrine and pressors as needed; neurogenic shock with bradycardia: norepinephrine with chronotropic support). | ||
| Line 30: | Line 30: | ||
** Hydroxocobalamin (cyanokit, occasionally used for cyanide-induced vasoplegia) | ** Hydroxocobalamin (cyanokit, occasionally used for cyanide-induced vasoplegia) | ||
** Midodrine (oral, chronic orthostatic hypotension; not for acute shock) | ** Midodrine (oral, chronic orthostatic hypotension; not for acute shock) | ||
** Droxidopa (oral norepinephrine | ** Droxidopa (oral, metabolised to norepinephrine; neurogenic orthostatic hypotension) | ||
== Notes on scope == | == Notes on scope == | ||