titration , vasopressors Understanding Vasoactive Medications Focus on Pharmacology and Effective Titration John M. Allen , PharmD, BCPS DOI: 10.1097/NAN.0000000000000022 H emodynamic instability is a common cause of morbidity and mortality in criti-cally ill patients. Each week we aim to involved at least 10-20 staff members as active participants in our in situ simulation sessions. To date, prospective examination of their impact on clinical outcomes in randomized trials has been minimal, despite their widespread use in cardiovascular illness. Common Vasopressors. ICU Masterclass: Inotropes and Vasopressors. Norepinephrine is the first-choice vasopressor in septic and vasodilatory shock. Here are a number of highest rated Vasopressor Medications pictures upon internet. Vasopressors are medications that constrict (narrow) blood vessels to create vasoconstriction in patients with extremely low blood pressure or shock. You will often hear the word ‘inotropes’ thrown around in ICU and it’s not often used correctly. ICU Basics: basic tips for surviving your rotation. The aim of the study is to determine the impact of a restrictive fluids strategy (vasopressors first followed by rescue fluids) as compared to a liberal fluid strategy (fluids first followed by rescue vasopressors) on 90-day in-hospital mortality in … Limited Beta-2 means even more clamp down time. Often used as the first line vasopressor in vasodilatory shock, norepinephrine is one of the most commonly used vasopressors. Alpha-adrenergic vasopressors work by stimulating the alpha-adrenergic receptor 1. Dobutamine and milrinone are inotropes. Vasopressor and inotropes are beneficial in shock states. The major vasopressors include phenylephrine, norepinephrine, epinephrine, and vasopressin. Goal was to reduce ICU length of stay by increasing the number of PT consults in this population; also to decrease the time from ICU admission to PT consult. Protocol EXCLUSIONS: Hemodynamic instability and/or high level vasopressor support. Key words: critically ill , intensive care unit , inotropes. Definitions Inotrope Increases cardiac contractility Vasopressor Induces vasoconstriction elevation of mean arterial pressure. The major vasopressors include phenylephrine, norepinephrine, epinephrine, and vasopressin. Dobutamine and dopexamine are synthetic catecho-lamines (having a similar chemical struc-ture to the endogenous catecholamines). vasopressors are catecholamines. ICU daily checklist. vasopressors. This figure describes the overall effect for vasopressors and ionotropes. This If a patient has a low blood pressure, we turn up the vasopressors. Figure. 1 Another large observational study revealed that 7.7% of critically ill patients had pleural … Critical Care Lecture Series ICU. Of the patients with late vasopressor administration, nearly one-half (1,639 of 3,429) transitioned to a new antibiotic or a new class of antibiotic within 24 h of the receipt of new vasopressors. Discuss how to investigate and the management principles behind each of the causes of shock. vasopressors. Norepinephrine. Inotropes : drugs that affect the strength of contraction of the heart muscle (myocardial contractility); negative inotropes decrease cardiac workload and blood pressure, and positive inotropes increase cardiac workload and blood pressure. What are the different classes of shock and give examples of each. You may need to be cared for in the ICU if you:have had major surgery, such as brain surgery, open heart surgery, coronary bypass surgery, or an organ transplanthave experienced major trauma such as a head injury or spinal cord injuryhave had a heart attack or strokehave serious burnscan’t breathe on your ownhave vital organ failurehave life threatening complications of diabetesMore items... Vasopressin but not norepinephrine improved renal blood flow and oxygen delivery and prolonged survival in animal models of septic shock. Shock may be distributive (e.g., septic shock) or cardiogenic. have excitatory and inhibitory actions on the heart and vascular smooth muscle, as well as important metabolic, central nervous system and presynaptic autonomic nervous system effects. The median ICU day for the start of late vasopressor administration was ICU day 6 (IQR, 5-7 days), with a median duration of 1 day (IQR, 1-2 days). We examine five ICU interventions: mechanical ventilation, vasopressor administration, red blood cell transfusion, fresh frozen plasma transfusion, and platelet transfusion. Inotropes and Vasopressors . The major vasopressors include phenylephrine, norepinephrine, epinephrine, and vasopressin. Other unique causes for blue toes in ICU patients. Dobutamine is considered the first-line inotrope in sepsis, and should be considered for patients with evidence of myocardial dysfunction or ongoing signs of hypoperfusion. A couple of examples are vasopressors (continuous IV medications to help raise blood pressure) and IV insulin (used to lower blood sugar in extremely hyperglycemic patients). Inotropes. See Appendix B. Clinical treatment decisions are variable and nuanced depending on patient, nursing, and attending factors. We studied compliance with blood pressure (BP) goals during VPI and whether a statistical model might be efficacious for advance warning of impending hypotension, compared with a basic hypotension threshold alert. Use dopamine as an alternative vasopressor agent to norepinephrine for the treatment of hypotension in patients with low risk of tachyarrhythmias and absolute or relative bradycardia. Among all patients in the ICU, vasopressors were given only on ICU days 1 to 3 in 11,939 hospitalizations (4,958 with ICU LOS < 4 days and 6,981 with ICU LOS ≥ 4 days), whereas 5,347 received them on day 4 or after. Vasopressors and. These are both medications which the bedside nurse titrates depending on vital signs, blood sugars, etc. Protocol is intended for the first 24hrs of ICU admission with reassessment of patient nutritional needs on daily rounds. If the patient is persistently hypertensive despite simple interventions or they have been admitted to ICU for the specific intent of treating hypertension then pharmacological therapy may be required. A pure vasopressor will typically cause a relative bradycardia. Common Sedatives Used in the ICU Mechanism of Action Dosing Pharmacokinetics Adverse Effects Propofol GABA+ NMDA-Bolus: 0.25-1 mg/kg Relative Max: 100 mg Infusion: 5-50 mcg/kg/min Max: 75 mcg/kg/min Onset: < 1 minute Duration: < 10 minutes May be slightly increased with prolonged infusions Metabolism: Hepatic Risk for Accumulation: Minimal Alpha>Beta. Inodilators are agents with inotropic effects that … In this episode I’ll review the vasopressors norepinephrine, vasopressin, epinephrine, dopamine, and phenylephrine. There is a need for evidence regarding alternative vasopressors as first-line vasopressors. In conclusion, inotropes and vasopressors play an essential role in the supportive care of a number of important cardiovascular disease processes. afterload. Stable patients did not receive any of the hemodynamic interventions in Table 1.Unstable patients received at least one of the interventions in Table 1 during the ICU stay, including the initiation of pressors or inotropes, administration of a significant dose of fluids in a short time period, or packed red … S.Shunker (CNC) ICU Liverpool Hospital . Inotropes and vasopressors are used to maintain BP Examples include noradrenaline, vasopressin 1. Vasopressors: a quick reference for use of common vasopressor agents. Experience. The way it’s often colloquially used generally infers ‘any drugs that providing an inotropic, chronotropic or vasopressor effect’ or ‘any drugs that are vasoactive’. Inotrope/vasopressor infusions MUST NEVER: Be bolused: will cause dangerously high BP & HR Be allowed to run out: will cause rapid drop in BP Be stopped or paused (unless discontinued by the ICU team) 2. and . Consider TTE in patients with evidence of cardiac dysfunction (elevated troponin) and hemodynamic instability to evaluate for cardiogenic shock. One day in the ICU costs roughly $2,500, whereas midodrine costs under $50/day. 2009. December 10, 2018. 2008;118:1047‐1056. 6–15,52–54, 63, 64 In general, these drugs are … Furthermore, ICU LOS was also evaluated in five studies, and no statistical significance was observed between the two groups with different orders in weaning vasopressors (mean difference 1.35, 95% CI -2.05 to 4.74, P = 0.44). Circulation. Journal of cardiovascular pharmacology and therapeutics. This article reviews the clinical manifestations of shock, as well as the vasoactive agents used to manage shock and what critical care nurses need to know about these important drugs. Vasopressors for Septic Shock (from the Surviving Sepsis Guidelines) See more from Surviving Sepsis Guidelines* *PulmCCM is not affiliated with the Surviving Sepsis Campaign. In human vasodilatory shock, the combination of low-dose vasopressin and norepinephrine was found to be safe and effective. Vasopressors are commonly applied to restore and maintain blood pressure in patients with sepsis. 10, 12,13 (Class I, Level A) 5.2. From November 2016 to April 2017, an anonymous web-based … Overgaard CB, Dzavik V. Inotropes and vasopressors: review of physiology and clinical use in cardiovascular disease. Consequently, what are examples of vasopressors? Do not use “renal dose” dopamine to preserve kidney function due to lack of evidence and potential toxicity. Dr. Matthews, the team leader, is calling out orders for drugs, x rays, and labs. List of Vasopressors: View by Brand | Generic. We identified it from well-behaved source. All conditions Adams-Stokes … 2. Two-thirds of ICU patients with COVID-19 may require vasopressors. Applied Sciences Lecture Course Inotropes & Vasopressors Dr Cathy Armstrong SpR In Anaesthesia & Clinical Fellow in Undergraduate Medical Education – A free PowerPoint PPT presentation (displayed as a Flash slide show) on PowerShow.com - id: 3bf804-ZWJhY It is an alpha and beta-1 agonist, although it does have a small effect on beta-2 receptors. For example, a patient with cardiogenic shock with acute decompensated heart failure. midline catheterThese are catheters placed in the arm, similar to a PICC, but shorter (typically 10-20 cm in length, terminating before the shoulder).Clinician-placed midlines are evolving as an alternative to either ultrasound-guided peripheral IVs or central lines.This is a rapidly emerging topic. ...More items... Vasopressor infusion (VPI) is used to treat hypotension in an ICU. Widely referred to in the US by the trade name Levophed, and in British-descent nations as “noradrenaline,” norepinephrine has become our first-line pressor for most routine … Answer (1 of 2): I presume you are referring to ‘vasopressors’, also known as inotropes - drugs used to elevate dangerously low blood pressure (as is often seen in sepsis, the commonest reason for critical care unit admission). See CXR 2 Pressure Vasopressor SBP≥ 100 or within 20-25 torr. S.Shunker (CNC) ICU Liverpool Hospital . Vasopressors increase vasoconstriction, which leads to increased systemic vascular resistance (SVR). Increasing the SVR leads to increased mean arterial pressure (MAP) and increased perfusion to organs. Inotropes increase cardiac contractility, which improves cardiac output (CO), aiding in maintaining MAP and perfusion to the body. So whats is a Vasopressor? Vasopressor infusion (VPI) is used to treat hypotension in an ICU. We aimed to evaluate the current practice and therapeutic goals regarding vasopressor use in septic shock as a basis for future studies and to provide some recommendations on their use. The drugs can be categorized into three groups: alpha-adrenergic, beta-adrenergic, and dopaminergic. If your patient aint tanked up right watch out for gut and peripheral LIMB ischemia. VASOPRESSIN Vasopressors and Inotropes Andrew Straznitskas, PharmD, BCCCP Clinical Pharmacist, Medical ICU NYC H+H/Bellevue. … Vasopressors given in an operating room or other procedural area should be excluded. Vasopressors differ from inotropes, which increase cardiac contractility; however, many drugs have both effects . Oral vasopressors may potentially reduce ICU length of stay, while avoiding complications such as central line infection and delirium. Ventricular filling pressures including PWP may fall resulting in ICU patients were classified into stable and unstable groups. The second mechanism, especially in the ICU setting is again pressors. The intention of this post is going to be to take a deep dive into the states of vasopressors using the best evidence based practices available. Vasopressors are a powerful class of drugs that induce vasoconstriction and thereby elevate mean arterial pressure (MAP). Jentzer JC, Coons JC, Link CB, Schmidhofer M. Pharmacotherapy update on the use of vasopressors and inotropes in the intensive care unit. 1. To count as a new vasopressor, that specific vasopressor cannot have been administered in the prior calendar day. Inotropes Critical Care Lecture Series ICU Objectives What are the different classes of shock and give examples of each. ⚠️ Currently, best available evidence indicates that midodrine should not be used to hasten weaning off vasopressor infusions among non-cirrhotic patients. PT-Established ICU early mobility program –QI Project QI project in large facility that used previous research to establish their criteria and apply to their facility between 2009-2011. The natu-rally occurring catecholamines (dopamine, noradrenaline, adrenaline) act as neuro-transmitters and hormones; their synthetic pathway is shown in Figure 1. Vasopressor: a class of drugs that induce arteriole vasoconstriction and thereby elevate blood pressure. Having said all that, ICU patients are “allowed” to have blue toes for many other reasons. Vasopressors for Hypoperfusion that does not respond to Fluid Resuscitation : Begin Norepinephrine 8mg/250mL D5W Starting dose 2mcg/min lactate > 4mmol/L Titrate 2mcg/min Q 5 minutes to maintain SBP >90mmHg or MAP ≥ 65mmHg Notify MD if … Vasopressors differ from inotropes, which increase cardiac contractility; however, many drugs have both vasopressor and inotropic effects. Shock is a physiologic state characterized by a significant reduction of systemic tissue perfusion, resulting in decreased oxygen delivery to the tissues. Norepinephrine, vasopressin, vasopressin. Company Name | City, State Registered Nurse, Cardiac ICU 08/2013 - Current. Clinical considerations In the ICU, patients receive an ongoing titration of vasopressor, with the need for constant adjustments to ensure MAP targets. Phenylephrine is one of the vasopressors that we used in my ICU, but not as frequently as Norepinephrine. Overview of the Management of … Advanced training in intra-aortic balloon pumps, Ventricular Assist Devices, Swans catheters, Continuous Renal Replacement Therapy/Dialysis, Central Venous/arterial lines management, intensive care hemodynamics. Physical fidelity is achieved […] The bomb for septic shock. Vasopressors in 2022. Vasopressors and Shock. The use of vasopressors and inotropes in the emergency medical treatment of shock. Vasodilators have effects opposite those of vasopressors. It shows the level of activity of each activity at each receptor. It seemed like the general order for which vasopressor we used went 1) Norepinephrine and 2) Vasopressin. Mechanical ventilation: a quick reference for ventilators. Vasopressors are a class of drug that cause vasoconstriction (increase Systemic Vascular Resistance) and thereby elevate MAP. Alpha-1 and Alpha-2 receptors work on vasculature to … and . 26. Examples include phenylephrine which is a 3. by Christopher R. Tainter, MD. Examples include phenylephrine which is a pure alpha-1 agonist, as well as vasopressin and angiotensin-II. Dopamine is a vasopressor with inotrope properties that is dose-dependent. Examples include ICU-IS-SIM is The Alfred ICU’s In Situ Simulation program, coordinated by Dr Chris Nickson. For example, a single-center study revealed that 27% of patients who were admitted to the ICU had pleural effusions that were identified via chest radiography. Do your own math calculations and ensure the stock solutions are the same concentrations as the examples below, or that you are making the correct adjustments. Vasopressor infusion (VPI) is used to treat hypotension in an ICU. Objectives: The objectives are to review safety and efficacy of vasopressors, pathophysiology, agents that decrease vasopressor dose, predictive biomarkers, β1-blockers, and directions for … Dopamine is a vasopressor with inotrope properties that is dose-dependent. We take this kind of Vasopressor Medications graphic could possibly be the most trending topic as soon as we portion it in google gain or facebook. These interventions represent a range of common ICU interventions with varying Last updated 02/18/2021. Vasopressors and inotropes are commonly used in the ICU. The resuscitation team is busy working on the patient, ensuring IVs are patent and the ET tube is properly positioned. They simply state: "In all cases, dosage of LEVOPHED should be titrated according to the response of the patient. Among patients admitted to the ICU for at least 4 days, late vasopressor administration occurred in 5.5% (3,429 of 62,206). January 2, 2022. The use of these potent agents is largely confined to critically ill patients with profound hae-modynamic impairment such that tissue blood flow is not sufficient to meet metabolic requirements. Dopamine is a vasopressor with inotrope properties that is dose-dependent. Critical care clinics. Use Up/Down Arrow keys to increase or decrease volume. ICU Scenario 50 Appropriate for: ICU/Neonatal Setting: Hospital A patient in the ICU has coded and CPR is in progress. Adrenergic Receptors Receptor Location Action Effect α1 Vasopressors Systemic Vasculature Vasoconstriction ↑ SVR β1 Inotropes Myocardium ↑HR … Key words: critically ill , intensive care unit , inotropes. In conclusion, inotropes and vasopressors play an essential role in the supportive care of a number of important cardiovascular disease processes. The ICU can be an intimidating and stressful environment. Pure vasoconstrictors only affect the peripheral vessels and do not have direct cardiac inotropic effects. There are two types of vasopressors: pure vasoconstrictors and catecholamines. The receptor selectivity of clinically used, catecholamine-based vasopressors and inotropes and hemodynamic effects are listed in Table 13-4. Vasopressors and Inotropes. 2008;26:759‐786, ix By acting on alpha receptors, norepinephrine causes vasoconstriction, increasing mean arterial pressure. This is typically performed within the unit, using real equipment, with team members performing their usual roles. Pleural effusions are common in patients who are treated in the intensive care unit (ICU). make vasopressors safer by enhancing communication pro-cesses around vasopressor use. Vasoactive agents, such as vasopressors and inotropes, are frequently needed to manage the patient in shock and prevent adverse outcomes. Conclusion: Vasopressors were used in about one fourth of ICU admissions and about one-fifth of ICU days. Vasopressors and inotropes Blood pressure Cardiac Output Low Normal Low Normal Phenylepherine Levophed (dopamine) Dopamine Levophed Epinepherine Or Dobutamine/phenyl nothing Dobutamine Milrinone. Inotrope/vasopressor infusions MUST NEVER: Be bolused: will cause dangerously high BP & HR Be allowed to run out: will cause rapid drop in BP Be stopped or paused (unless discontinued by the ICU team) 2. Inotropes and Vasopressors . RESULTS: Among the 62,206 hospitalizations with at least 4 ICU days, late vasopressor administration occurred in 5.5% (3,429 of 62,206). Assumptions: Crisis ICU staffing ‣ Staffing models are suggestions / starting points ‣ Each ICU will assess capacity and personnel capabilities at least daily ‣ Personnel may be subject to “battlefield promotion” ‣ For non-ICU personnel, NPs, PAs, and non-CC capable physicians of all ranks are equivalent (in crisis conditions) Low SV, DO2. Medicines — including synthetic hormones — that are used as vasopressors include: Norepinephrine; Epinephrine; Vasopressin (Vasostrict) Dopamine; Phenylephrine; Dobutamine Distributive shock is commonly caused by sepsis, neurogenic shock, and anaphylaxis. Inotropes and vasopressors are biologically and clinically important compounds that originate from different pharmacological groups and act at some of the most fundamental receptor and signal transduction systems in the body. 3. There are many potential interventions available in ICU data. To date, prospective examination of their impact on clinical outcomes in randomized trials has been minimal, despite their widespread use in cardiovascular illness. By eddyjoemd In Vasopressors. 25(4):781-802, ix. Venodilation results in decreased pre-load. Pure vasoconstrictors only affect the peripheral vessels and do not have direct cardiac inotropic effects. Vasopressors cause vasoconstriction resulting increased systemic and/or pulmonary vascular resistance (SVR, PVR) — e.g. Episode 5: Vasopressors In Shock – A Review for PGY-1 Pharmacy Residents. have excitatory and inhibitory actions on the heart and vascular smooth muscle, as well as important metabolic, central nervous system and presynaptic autonomic nervous system effects. Physiology of Vasopressors and Ionotropes. Vasopressors increase vasoconstriction, which leads to increased systemic vascular resistance (SVR) 1). Inotrope and vasopressor therapy of septic shock. Access Its submitted by executive in the best field. Norepinephrine is considered the first-line vasopressor for patients with sepsis-associated hypotension. Vasopressors are classified as drugs that are designed to increase arterial pressure by peripheral vasoconstriction. Use of inotropes & vasopressors To support the failing heart To support the failing peripheral vasculature To correct hypotension during anaesthesia (general or regional) 4. the timing of vasopressor administration with posthospitalization discharge mortality. rn, icu, charge nurse Professional Summary Caring Nurse with total of 5 years and 4 months of experience in Medical ICU, 10 total years of experience in Home Health setting, and a dedication to best-in-class patient services through effective critical care planning and management. Inotropes and vasopressors are used to maintain BP Examples include noradrenaline, vasopressin 1. Vasopressor Drugs Always confirm current dose recommendations in a reputable formulary or other publication. Inotropes. Vasopressor Medications. What are the different crystalloids and colloids available for resuscitation? Inotropes are drugs that increase myocardial contractility (inotropy) — e.g. Vasopressors are indicated if you think the patient will benefit from vasoconstriction and elevated mean arterial pressure. 20(3):249-60. Distributive shock is commonly caused by sepsis, neurogenic shock, and anaphylaxis. Distributive shock is commonly caused by sepsis, neurogenic shock, and anaphylaxis. Discuss how to investigate and the management principles behind each of the causes of shock. There were 102 ICU stays with at least one sustained episode of hypotension during vasopressor infusion. Vasopressors and Inotropic Agents UCI Internal Medicine Residency Mini-Lecture Series Objectives Understand the vasopressor and inotropic agent receptor physiology ... – A free PowerPoint PPT presentation (displayed as a Flash slide show) on PowerShow.com - … MBP ≥ 80 of patient's Nl. titration , vasopressors Understanding Vasoactive Medications Focus on Pharmacology and Effective Titration John M. Allen , PharmD, BCPS DOI: 10.1097/NAN.0000000000000022 H emodynamic instability is a common cause of morbidity and mortality in criti-cally ill patients. Have knowledge of the mechanism of action of commonly used … Examples of commonly-used vasopressors include norepinephrine, epinephrine, vasopressin, phenylephrine, dopamine [5]. Dobutamine and milrinone are inotropes. Vasopressors are provided for septic shock that does not respond to fluid resuscitation. On June 2, 2020. Route: Initiate enteral feeding via Oral gastric tube, unless route otherwise ordered by physician. Accelerated weaning from vasopressors ⚠️ The MIDAS trial suggests that midodrine is not effective at accelerating the weaning off IV vasopressors among most ICU patients. Background: Vasopressors are administered to critically ill patients with vasodilatory shock not responsive to volume resuscitation, and less often in cardiogenic shock, and hypovolemic shock. Emerg Med Clin North Am. Fluids, vasopressors, and inotropes are the essential parts of the treatment of shock. Initiation of a new vasopressor infusion (norepinephrine, dopamine, epinephrine, phenylephrine, OR vasopressin). However, if there is a major element of β1 stimulation, tachycardia may be observed. Terminology is listed below: internal audit of vasopressor use A multidisciplinary team of ICU clinicians (i.e., nurses, inten-sivists and pharmacists) audited vasopressor use for three consecutive weeks in the three ICUs of the hospital. For example, even the FDA has no "upper limit" for norepinephrine. The beta tries to kick the CO up, but cardiac depression can occur if lacking adequate Preload/Inotropic support. Faster transition from the ICU could facilitate greater mobility, avoiding deconditioning. March 3, 2017 by drnandyala. Vasopressors. 2. Oral vasopressors could also reduce costs. Access There are two types of vasopressors: pure vasoconstrictors and catecholamines. Filter by. Intensive Care Topics: common admissions and useful algorithms. Obviously many hypotensive patients in the ICU receive vasopressors that lead to acrocyanosis as outlined above. Dobutamine and milrinone are inotropes. Ensure adequate analgesia and sedation, stop vasopressors and inotropes and reassess fluid status and consider diuretics if necessary. In this course, you’ll learn a systematic, hands-on approach for the use of vasopressors and inotropes. This creates an imbalance between oxygen delivery and oxygen consumption. For example, a patient who is hypotensive due to septic shock and its associated vasodilatation. VASOPRESSORS IN ICU. Retrospective data were obtained from a public database. A total of 175 patients accounting for 215 ICU stays from Hospital 1 were identified as patients receiving at least 30 minutes of vasopressor mono-therapy at sub-maximal doses. Levophed (norepinephrine)-----> Big bad daddy of vasopressors. Introduction. vels are inappropriately low in adults with severe sepsis but not in children with meningococcal septic shock. Norepinephrine (Levophed), epinephrine, vasopressin, phenylephrine (Neo-Synephrine), and dopamine are the … Hollenberg SM. 10,18,19 The ICU is like an extension of the ER. ER doctors do all of the stabilizing measures, make sure that people are all wrapped up, and then they will be sent to the ICU, where they can be taken care of long term. Intensive care and emergency room are two different areas of a hospital. Hemodynamic support for unstable patients can be a daunting process. Actions of Vasopressors. This manual is intended to help support medical students, interns, and residents working in the ICU. Ellender TJ, Skinner JC. Objectives. We emphasize that vasopressors should be administered simultaneously with fluid replacement to prevent and decrease duration of hypotension in shock with vasodilation. 2015. Please be mindful that this manual is a guide for care in the ICU. contractility whereas vasopressor agents are administered to increase vascular tone. Vasopressor drugs have different mechanisms of action depending on the type of drug. High HR, Resistances 3 Flow Inotrope Signs of perfusion DO2 Low BP, SV, Resistances Priority # Physiology to improve Intervention Parameter to target PAC targets Avoid 1 Volume Fluids CVP 10-15 DO2 Low Sao2

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