What is the management of vasoplegia in trauma patients with hypotension?

From the Guidelines

The management of vasoplegia in trauma patients with hypotension should start with fluid resuscitation using crystalloid as the initial fluid of choice, followed by the use of norepinephrine as the first-line vasopressor if hypotension persists. This approach is supported by recent guidelines, including a 2024 study published in Critical Care Medicine 1, which emphasizes the importance of crystalloid fluid resuscitation and the use of norepinephrine in the management of hypotension.

Key considerations in the management of vasoplegia in trauma patients include:

• Initial fluid resuscitation with crystalloid to restore intravascular volume
• Use of norepinephrine as the first-line vasopressor if hypotension persists, typically started at 0.05-0.1 mcg/kg/min and titrated to maintain a mean arterial pressure (MAP) of at least 65 mmHg
• Addition of vasopressin as a second agent at a fixed dose of 0.04 units/min if norepinephrine requirements are high, as suggested by the study 1
• Consideration of other vasopressors such as epinephrine or phenylephrine for refractory cases
• Use of hydrocortisone for patients with vasopressor-resistant shock

The pathophysiology of trauma-induced vasoplegia involves excessive vasodilation due to inflammatory mediator release, endothelial damage, and autonomic dysfunction, which explains why both volume replacement and vasoconstrictors are needed to restore vascular tone and maintain adequate tissue perfusion. Continuous hemodynamic monitoring is essential, ideally with arterial line placement for accurate blood pressure readings. The goal of treatment is to restore adequate tissue perfusion and prevent organ dysfunction, with a focus on minimizing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

2.2 Hypotension associated with Septic Shock Dilute 10 mL (1 mg) of epinephrine from the syringe in 1,000 mL of 5 percent dextrose solution or 5 percent dextrose and sodium chloride solution to produce a 1 mcg per mL dilution. To provide hemodynamic support in septic shock associated hypotension in adult patients, the suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min, and is titrated to achieve a desired mean arterial pressure (MAP).

The management of vasoplegia in trauma patients with hypotension involves the use of inotropes such as epinephrine to provide hemodynamic support. The dosing infusion rate of epinephrine is titrated to achieve a desired mean arterial pressure (MAP), with a suggested rate of 0.05 mcg/kg/min to 2 mcg/kg/min 2.

• Key points:
  • Epinephrine is used to manage hypotension associated with septic shock.
  • The dosage of epinephrine may be adjusted periodically to achieve the desired blood pressure goal.
  • Inotropes play a crucial role in managing vasoplegia in trauma patients.

From the Research

Management of Vasoplegia in Trauma Patients

The management of vasoplegia in trauma patients with hypotension is a complex process that requires prompt treatment to prevent patient morbidity and mortality.

• Vasoplegia is characterized by persistently low systemic vascular resistance (SVR) and resistant hypotension in the presence of a normal cardiac index despite aggressive resuscitation attempts 3.
• Treatment of vasoplegia involves the use of vasopressors such as vasopressin, norepinephrine, and hydroxocobalamin 4, 3.
• Some evidence suggests that the addition of methylene blue to the treatment regimen may result in a reduction in overall norepinephrine equivalent vasopressor requirements, increased mean arterial pressure, and an improved clinical course 4, 5, 6.

Importance of Inotropes in Trauma Patients

Inotropes, such as norepinephrine and vasopressin, play a crucial role in the management of vasoplegia in trauma patients.

• The use of vasopressors in severely injured trauma patients is often discouraged due to concerns that vasoconstriction will worsen organ perfusion and result in increased mortality and organ failure 7.
• However, the pathophysiology of traumatic shock is complex and involves multiple neurohormonal interactions that are ultimately manifested by an initial sympathoexcitatory phase that attempts to compensate for acute blood loss and is characterized by vasoconstriction, tachycardia, and preserved mean arterial blood pressure 7.
• The objectives of hemodynamic resuscitation in hypotensive trauma patients are restoring adequate intravascular volume with a balanced ratio of blood products, correcting pathologic coagulopathy, and maintaining organ perfusion 7.

Treatment Options

Several treatment options are available for the management of vasoplegia in trauma patients, including:

• Methylene blue: has been shown to improve hemodynamics and reduce vasopressor requirements in patients with vasoplegia 4, 5, 6.
• Vasopressin: is often used in combination with norepinephrine to treat vasoplegia 4, 3.
• Hydroxocobalamin: has been shown to improve hemodynamics and reduce vasopressor requirements in patients with vasoplegia 4, 3.
• Norepinephrine: is often used as a first-line treatment for vasoplegia, but may not be effective in all patients 4, 3.