No evidence of effectiveness or indeed efficacy or inotropes in cardiogenic
shock, so there's not going to be much in the way of sensible argument that
one is better than another. Phosphodiesterase inhibitors were pretty popular
a few years back (but worsened outcome sadly).
Best policy would be:
1. Reiterate that there is no evidence that these things work and you won't
use them until you get the evidence.
2. Put in a PA catheter and fiddly about with different inotropes until you
hit the Forrester criteria- particularly good for optimising filling with a
RV MI (if you don't stick the end of your catheter through the infarcted
bit).
3. Ask your own ITU what their policy is and adopt it.
Which you pick depends on how bolshy and invasive you like being (my own
choice fluctuates between maximum annoyance to intensivists and maximum
invasiveness).
Personally wouldn't give adrenaline to allow GTN- I'd give GTN (as a
venodilator) to optimise filling (and yes, what optimising is is up for
debate) as long as not a RV MI, then consider (and probably reject)
adrenaline as a driver. But wouldn't use it in the hope it's alpha effects
will antagonise the venodilator effect of nitrates.
I agree with your medics- patients on adrenaline should be on a HDU- ideally
managed pretty invasively. You don't want to keep up BP with pure alpha
effects while extending your MI and not achieving any output. Even better,
consider transferring for rescue revasularisation.
> Is their any useful EBM out there? My search got bugger all.
A good search, then. You picked up all the evidence with it.
Matt Dunn
Warwick
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