[Music] I'd like to start by saying thank you so much to Haney for the privilege and honor of speaking at recess X 2022 my name is Dennis Kim and over the course of the next 10 to 12 minutes we're gonna go over a fairly controversial topic namely vasopressors and Trauma yes or never I have no Financial disclosures and to start the talk we're going to talk about vasopressors as a never event followed by a rationale for the use of vasopressors and Trauma we'll take a look at what the literature tells us and we'll conclude with some final take-home points I wish I could look out into the audience and see a show of hands to see how many people could honestly and legitimately agree with this statement never have I ever administered basal pressures to a trauma patient I for one cannot say that I've never done this because I've done it on multiple occasions typically these patients come in with spinal cord injuries now this is very uncommon but if someone does have a cervical spinal cord injury with neurogenic shock in addition to getting IV access filling the tank these patients oftentimes need to be bridged with vasopressors to restore a reasonable map what the target is 85 and for how long five seven days uncertain but just an example of when we would use vasopressors and Trauma also patients who have prolonged pre-hospital transport times might also benefit from some low-dose vasopressors to maintain some minimal map during that transport process finally and I think all of us in the audience can relate to this one when someone is in distress and gets intubated whether that's for septic shock or in our case hemorrhagic shock and you do an ABC versus a cab approach once you give those medications and simple the lights your patient and then give them positive pressure breaths these patients will become hypotenses which is why we're usually ready with some norepinephrine to infuse in order to maintain a pressure in a recent survey of European trauma care providers up to 80 percent of providers believe that there was a role for early vasopressors in the trauma Bay now what would the rationale for vasopressors and Trauma be the argument goes something along the lines of this number one we know that excessive fluid resuscitation may be detrimental and contribute to adverse outcomes abdominal compartment syndrome ards Cardiac and Pulmonary dysfunction inflammation and coagulopathy therefore volume sparing resuscitation in the form of vasopressors May ultimately reduce morbidity and may be used as a bridge to therapy further we know that in hemorrhagic shock certain levels of hormones like origin and vasopressin may become deficient and in patients who are AVP deficient we know that their catecholamine resistant and therefore supplementing patients with vasopressin shunts blood away from non-essential to critical organs it may also augment blood pressure and also assists with hemostasis we know that with the early response to blood loss we have a sympathetic response that's going to result in increased release of catecholamines vasoconstriction which will increase your svr and ultimately your mean arterial pressure additionally local hemostasis is taking place but if that bleeding and shock continues unabated and unchecked ultimately we get nitric oxide production vasodilation and that oftentimes precedes complete cardiovascular collapse and I think very few of us would argue that at that point vasopressors would be indicated trauma or not but what does the literature say about the use of vasopressors and Trauma in one of the most highly cited retrospective reviews of early use of vasopressors early being within the first 24 hours after injury sparian colleagues found that patients who received early vasopressors were actually much more severely injured with worse endpoints of resuscitation more likely to be hypotensive receive more blood products and operative interventions not surprisingly mortality was also higher so these aren't really well matched groups but on multivariate logistic regression analysis accounting for the type of vasopressor and the risk for mortality you can see phenylephrine norepi and dopamine of Interest they didn't include things like EPI and dobutamine and included that in the non-vasopressor group all were associated with an increased mortality of Interest vasopressin does cross that line of significance they also looked at the use of aggressive early crystalloid resuscitation within the first 12 to 24 hours and interestingly this was not associated with an increased risk for mortality in another study of early vasopressor use which tried to account for volume status by one of my old partners and friends pluretinol they looked at survivors and non-survivors who did or didn't get phase oppressors what they found was that patients who got vasopressors which more likely to die there's a big difference in terms of the Baseline demographics but interestingly they looked at CVP they defined hypo and hypervolemic as a dichotomous number greater than or less than eight there's so many issues with CVP we know that but again this is back in 2011 and when they perform their multivariate regression analyzes not surprisingly vasopressive use associated with mortality when they forced hypovolemia into the independent risk factors for death in the patients who were getting vasopressors they found that the volume status as defined by CVP of less than or greater than a didn't really make a much of an impact there was a systematic review there was about six studies included in this of which only one was a prospective randomized trial with that said it was specifically looking at vasopressin severely underpowered and stopped early for inability to accrue patients so that has to be taken with a grain of salt and the remaining observational studies both unadjusted as well as adjusted short-term mortality you can see that vasopressor use was associated with an increased risk for mortality lots of issues here with regards to selection bias as well as prognostic differences between groups at the beginning of the studies and so very difficult to say whether or not early vasopressor use is bad but I think when you look at all these different studies time and time again that there seems to be an association between early vasopressor use and death now again it's not causality it's an association and we have to bear in mind that the vast majority of these studies the Baseline demographics are completely unequal and patients who are getting vasopressors are probably doing so because they're actively dying now the avert trial has received a lot of attention since being published in 2019 and this is a study looking at low-dose AVP supplementation in patients who received at least six units of blood within the first 12 hours and about a hundred percent of patients in this study either went to angioembolization or the operating room for definitive Hemorrhage control and what they found was that patients who received low-dose AVP actually had an overall decrease in their transfusion requirements up to about 1.4 liters of rbcs and ffp so pretty significant finding in that particular study I think the great thing about all these studies is that it brings up more questions than answers what do we exactly mean by early what about elderly and brain injured patients should all vasopressors be considered equally harmful and are vasopressor is really just a marker for injury severity I think in general early you'll see in most of these studies that means within the first 24 hours for me I think early would be before you actually volume resuscitate patients again in the age of mtps and post-proper we're going to be giving these patients one to one resuscitation txa and make sure they're up in the or getting Hemorrhage control bleeding from an IVC injury patient did great what about elderly and brain injured patients none of these studies include these patients so can't tell you one way or the other if they're harmful and no not all vasopressors are considered equal and at this point vasopressin has the best literature supporting its early use again titrated to a map of 65 for the first couple of days results in decreased use of allogenic blood products and I do think vasopressors are probably just more of a marker for injury severity rather than the cause and these are my kind of vasopressors tourniquets binders fingers on a blood vessel so ultimately in terms of take-home points I think early vasopressor use if we're going to go by the literature which is mainly comprised of observational studies is associated with adverse outcomes our primary and number one priority should be to identify and stop bleeding low dose vasopressors after bleeding control and specifically vasopressin is probably a reasonable alternative [Music]