Small Animal Emergency and Critical Care Medicine: Self-Assessment Color Review, Second Edition, Q&A 03
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Student tip: This case is an excellent overview of the pharmacological intervention required when BP drops. |
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'You have provided analgesics and fluid resuscitation for hypovolemic shock for a dog with pyometra. Isotonic balanced crystalloids and HES were infused using large volume resuscitation techniques to high end end-points. Post-infusion parameters are: CVP = 10 cmH2O; HR = 150 bpm; CRT = 2 sec; MM pale pink; weak femoral pulses; Doppler SABP = 78 mmHg; blood lactate = 3.5 mmol/l (31.5 mg/dl) (5.0 mmol/l [45 mg/dl] before fluids).
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| List at least five parameters or conditions that can contribute to non-responsive shock. | Inadequate volume administered; pain; ongoing fluid loss; third-body fluid spacing; hypoglycemia; electrolyte disorders; acid–base disorders; cardiac arrhythmias; myocardial depression or failure; organ ischemia; anemia; brainstem pathology; excessive vasodilation or vasoconstriction; hypoxemia; hypercarbia; cardiac tamponade; decreased venous return.
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| Arterial blood gas, glucose, electrolyte panel, and hematocrit are normal. What step(s) are taken next to improve perfusion? | The CVP of 10 cmH2O implies adequate central volume (unless right heart failure or pericardial effusion). A fluid challenge with 5–10 ml/kg of HES can be done to detect the effect on CVP and SABP with additional fluids. Inadequate response to fluid challenge is indication for pharmacologic management of BP.
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| Which of the following drugs might be used to treat non-responsive shock? How do they work? Dobutamine, dopamine, norepinephrine, Oxyglobin®, esmolol, diltiazem. | Dobutamine is a direct stimulant of beta1 receptors of the sympathetic nervous system and would be indicated for depressed myocardial contractility. Dopamine is an inotropic and vasopressor catecholamine and is often a first-line agent for pharmacologic BP support. Norepinephrine increases BP by increasing vascular tone through alpha adrenergic receptor activation. Oxyglobin® is polymerized bovine hemoglobin that acts as a colloid, carries oxygen, and has mild vasopressor activity. Esmolol is a selective beta1 receptor blocker that is only indicated if a severe tachycardia is responsible for the poor cardiac output. Diltiazem injectable is a calcium channel blocker only indicated if a severe tachycardia is responsible for the poor cardiac output.
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