Written by Clay Smith
These authors argue for a nuanced approach to using vasopressors in hypotensive trauma patients.
Why does this matter?
You may have heard the dogma that trauma patients should not get vasopressors. Often, shock is as a result of hemorrhage. Hence, the quip – they’re not bleeding out epinephrine! Whie we certainly don’t want to push the BP back to normal before fixing the holes in the patient, is there ever a role for pressors in trauma?
They’re not bleeding out epinephrine, right?
These authors argue that there is certainly a role for early hypotensive resuscitation, but that once the holes are fixed, volume restored, and hypotension persists that pressors have a role. Persistent hypotension can worsen perfusion, organ dysfunction, and coagulopathy. And we certainly don’t want to overdo it with crystalloid boluses. Therefore, the authors argue for pressors in these cases. Though they don’t argue that patients are bleeding out epinephrine, they do make the point that there is depletion of vasopressin and likely norepinephrine in some prolonged shock states. They bolster their argument for judicious pressors with several retrospective studies and a couple of RCTs using vasopressin, which were promising. And there is certainly a role in the more clear cut cases of, “traumatic brain injury, spinal cord injury, multiple organ dysfunction syndrome, and vasodilation of general anesthetics.” It seems there is room for a nuanced approach when it comes to vasopressors for some hypotensive trauma patients.
Vasopressors in Trauma: A Never Event? Anesth Analg. 2021 Jul 1;133(1):68-79. doi: 10.1213/ANE.0000000000005552.