TREATING SEPSIS

Epinephrine

Epinephrine (adrenaline) is the original inotrope/vasopressor, and indeed it is what “God gave us” to deal with shock. It remains the agent of choice when patients are in-extremis – such as in anaphylactic shock or cardiac arrest. Otherwise, we now reserve the use of epinephrine as an add on vasopressor (with norepinephrine) or when the cause of hypotension is unclear (it is a most reliable “backs to the wall” pressor). Epinephrine has potent beta-1, beta-2 and alpha-1 adrenergic activity, though the increase in mean arterial pressure in sepsis is mainly from an increase in cardiac output (stroke volume). There are three major drawbacks from using this drug: 1. It increase myocardial oxygen demand. 2. It ncreases serum lactate – this may be due to either worsening of perfusion to certain tissues, or due to a calorigenic effect (increased release and anaerobic breakdown of glucose). 3. Epinephrine appears to have adverse effects on splanchnic blood flow. Meier-Hellmann and colleagues   (1) compared epinephrine with dobutamine plus norepinephrine. The effect on global hemodynamics and oxygen transport was similar, but epinephrine reduced splanchnic oxygen delivery, consumption, pHi (gastric mucosal pH) and increased serum lactate levels.

References

(1)   Meier-Hellmann A, Reinhart K, Bredle DL, Specht M, Spies CD, Hannemann L. Epinephrine impairs splanchnic perfusion in septic shock. Crit Care Med 1997; 25(3):399-404.

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