Cite this post as:
Scott Weingart, MD FCCM. Vasodilators for Severe Sepsis. EMCrit Blog. Published on August 30, 2011. Accessed on April 20th 2024. Available at [https://emcrit.org/emcrit/vasodilators-for-severe-sepsis/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: August 30, 2011
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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This opens up more questions than answers: 1) Doesn’t it depend where on the Starling curve the patient is following volume resuscitation or pressor support? 2) Does an elevated MAP represent pathology, over-treatment (iatrogenesis) or the normal physiological state of the patient? 3) Which part of the microcirculation are we actually targeting and to what end? (sepsis represents an overall vasoplegic, dilated state with a combination of inappropriate perfusion of some vascular beds and underperfusion of other vascular beds) 4) Is really possible to target with any precision, the venous or arterial side of the circulation with vasodilators (let alone… Read more »
All good questions! All treatments must be evaluated in the individual patient. Guidelines and protocols give a starting recipe. The art is being a chef and altering based on the humidity, the quality of you ingredients, and the individual ineffable factors of the day.
With respect to Docxology’s post, the Starling Relationship is probably of limited usefulness as a conceptual tool for the evaluation of the hemodynamic relationships in the patient with sepsis syndrome. The principle and earliest macro-hemodynamic derangement of sepsis may be the inappropriate level of after-load reduction resulting from shunting of flow across the microcirculation and bypass or stasis within the capillary perfusion beds. In the referenced article above by Spronk et al, use of orthogonal polarization spectral imaging of the lingual mucosa reveals in ways that words fail to convey the profound dysfunction of the microcirculatory beds and their impressive… Read more »
In response to Dr. Meissner, “With respect to Docxology’s post, the Starling Relationship is probably of limited usefulness as a conceptual tool for the evaluation of the hemodynamic relationships in the patient with sepsis syndrome.” I never claimed as such. “Sepsis is quintessentially a disease of the microcirculation, which when detected in its earliest stages is highly responsive to therapy, but left to deteriorate and percolate, becomes the highly lethal entity we encounter too often in ER & ICU patients.” Macrocirculatory function can be addressed i.e. MAP, CO, SVRI with vasopressors and inotropes. The question is whether or not any… Read more »
The macro-circulatory defect in septic shock is low SVR via vasodilation of the small muscular arteries. The micro-circulatory defect is afferent pre-capillary arteriolar vasoconstriction and vasodilitation of the efferent post-capillary venules resulting in capillary leak &/or microcirculatory shunting. The putative effect of nitroglycerin in septic shock is to help re-establish normal pressure-flow relationships in the microcirculation. These effects of course must be counter-balanced with any macrocirculatory effects of the NTG infusion via titration of pressors. My comment about tachycardia and tachykpnea was in-exact, what I meant to say, but did not say, was that while the recognition of tachycardia and… Read more »
A nice little review. We have blunt tools for the microcirculation.
http://anaesthetics.ukzn.ac.za/Libraries/Documents2011/Dr_Alphonsuss_FMM_Booklet.sflb.ashx
will read asap