What is the order of inotropes (inotropic agents) to be started in trauma patients with hypovolemic shock intraoperatively?

From the Guidelines

In trauma patients with hypovolemic shock intraoperatively, norepinephrine should be started as the first-line vasopressor to maintain mean arterial pressure (MAP) ≥ 65 mm Hg, followed by the addition of vasopressin or epinephrine as needed. Before initiating any inotropes, it is crucial to prioritize adequate volume resuscitation to restore intravascular volume, as guided by the ERAS® Society recommendations 1. The use of norepinephrine as the initial agent is supported due to its both vasoconstrictor effects and some beta-agonism to support cardiac contractility 1.

The selection of subsequent inotropic agents depends on the patient's response to initial therapy and their specific hemodynamic needs. Vasopressin can be added to norepinephrine to raise mean arterial pressure 1, while epinephrine can be used to maintain adequate blood pressure or increase cardiac output. It's essential to monitor patients closely, using minimally invasive cardiac output devices and arterial lines to guide the use of inotropes and vasopressors 1.

Key considerations in the management of these patients include:

• Maintaining a MAP target of ≥ 65 mm Hg to reduce end-organ injury 1
• Avoiding excessive vasopressor doses, which may increase the risk of mortality 1
• Titration of inotropic agents based on individual patient response and hemodynamic monitoring
• The safety of starting norepinephrine via a large peripheral vein in shocked patients until central access is established 1

From the Research

Order of Inotropes in Trauma Patients with Hypovolemic Shock

• The order of inotropes to be started in trauma patients with hypovolemic shock intraoperatively is not explicitly stated in the provided studies, but we can infer the general approach to vasopressor and inotrope therapy in shock patients.
• According to 2, norepinephrine (NE) is an appropriate choice as a first-line vasopressor titrated to achieve an adequate arterial pressure due to a lower risk of adverse events than other catecholamine vasopressors.
• If tissue and organ perfusion remain inadequate, an inotrope such as dobutamine may be added to increase cardiac output to a sufficient level that meets tissue demand 2.
• Low doses of epinephrine or dopamine may be used for inotropic support, but high doses of these drugs carry an excessive risk of adverse events when used for vasopressor support and should be avoided 2.
• A study comparing dopamine and norepinephrine in the treatment of shock found that there was no significant between-group difference in the rate of death at 28 days, but dopamine was associated with more arrhythmic events than norepinephrine 3.
• In cardiogenic shock, norepinephrine may be preferred over epinephrine, and dobutamine represents the first-line inotrope agent when norepinephrine fails to restore perfusion 4.

Considerations for Trauma Patients

• The pathophysiology of traumatic shock is complex and involves multiple neurohormonal interactions, and the use of vasopressors may be useful in traumatic shock resuscitation to counteract vasodilation in hemorrhage 5.
• The practice of hypotensive resuscitation in trauma patients is not supported by consistent clinical data, and excessive volume resuscitation is associated with adverse clinical outcomes 5.
• A nuanced approach to vasopressor administration in the resuscitation of traumatic shock is necessary, taking into account the patient's condition and the goals of hemodynamic resuscitation 5.