transfusion strategy should be adopted and is generally indicated only in those
patients with significant hypovolemia or anemia (i.e.) Hb < 7g/dL. SvO 2 and
lactate measurements should be obtained with the goal to be >70% and <2
mmol/L, respectively (need reference).
VI Inotropic Agents
Pharmacotherapy using inotropic medications can be used effectively to
improve cardiac function by increasing CO and contractility. Their effects are
generally dose dependent. However, prolonged use or high doses can have
deleterious effects on the heart that include: arrhythmogenesis, excessive
chronotropy, increased myocardial oxygen consumption, down regulation of B-
adrenergic receptors, increased afterload, and hypertension. Inotropic
“resistance” may also be observed in the context of concurrent acidosis. Sodium
bicabonate may be helpful in this situation.
The initiation of inotropic support and the choice of medication are based
on the clinical response to volume expansion and the correction of the metabolic
acidosis. In patients with persistent low systolic blood pressures but peripheral
vasodilation and SvO 2 > 70% (i.e. warm shock), consideration should be given to
the use of norepinephrine and/or vasopressin. In patients with an SvO 2 <70%,
normal blood pressures but poor peripheral perfusion, a blood transfusion (to get
Hb > 10g/dL) and the use of milrinone, nitroprusside or dobutamine should be
considered. In patients with an SvO 2 <70%, low blood pressure and poor
peripheral perfusion (i.e.) cold shock, optimization of Hb > 10 g/dL and an