What is the management plan for a 46-year-old female with breast cancer, presenting with hypotension (blood pressure 90/50mmHg), who has undergone titration of norepinephrine (NorEpi) at 10 micrograms per minute and subsequently developed severe hypotension (blood pressure 80/40mmHg), tachycardia (heart rate 165), and received Atrovent (ipratropium bromide) nebulization?

From the Guidelines

This patient requires immediate intervention to address worsening hypotension, and I recommend increasing the norepinephrine infusion by 2-5 mcg/min increments every 5 minutes until achieving a target mean arterial pressure (MAP) of at least 65 mmHg, as supported by the most recent guidelines 1. The patient's vital signs indicate hemodynamic instability, with a drop in blood pressure from 90/50 to 80/40 mmHg, tachycardia (PR 165), and tachypnea (RR 32).

• The use of norepinephrine as the first-line vasopressor agent is recommended to correct hypotension in septic shock, as stated in the 2016 WSES consensus conference 1.
• Additionally, administering a 500 mL fluid bolus of crystalloid solution may help address potential hypovolemia, unless contraindicated by heart failure or volume overload, as suggested by the Surviving Sepsis Campaign guidelines 1.
• The patient's oxygen saturation should be maintained above 92% with continued oxygen therapy, and arterial blood gas analysis may be considered to assess acid-base status and lactate levels as markers of tissue perfusion.
• Close monitoring of vital signs every 15 minutes is essential until stabilization, and preparation for possible ICU transfer should be considered if the patient does not respond to initial interventions.
• It is also important to note that the patient may be experiencing septic shock secondary to her cancer or treatment, or potentially cardiogenic shock if she has received cardiotoxic chemotherapy, and a thorough evaluation of her condition is necessary to guide further management, as recommended by the 2016 SCC guidelines 1.

From the FDA Drug Label

Administration in saline solution alone is not recommended Average Dosage: Add the content of the vial (4 mg/4 mL) of LEVOPHED to 1,000 mL of a 5 percent dextrose containing solution. After observing the response to an initial dose of 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute, adjust the rate of flow to establish and maintain a low normal blood pressure (usually 80 mm Hg to 100 mm Hg systolic) sufficient to maintain the circulation to vital organs In previously hypertensive patients, it is recommended that the blood pressure should be raised no higher than 40 mm Hg below the preexisting systolic pressure. The average maintenance dose ranges from 0. 5 mL to 1 mL per minute (from 2 mcg to 4 mcg of base). The patient's current blood pressure is 80/40 mmHg, which is within the target range of 80 mm Hg to 100 mm Hg systolic.

• The current dose of 10 mcg/min of NorEpi should be adjusted to maintain the target blood pressure range.
• Since the patient's blood pressure is already at the lower limit of the target range, the dose of NorEpi should be decreased to avoid excessive vasoconstriction and potential organ hypoperfusion 2.

From the Research

Patient Assessment

• The patient is a 46-year-old female with breast cancer, currently experiencing shock with a blood pressure of 90/50mmHg at 9:50Am and 80/40mmHg at 10:30Am 3, 4.
• The patient's vital signs at 10:30Am include:
  • Oxygen saturation: 92% at 10Lpm
  • Pulse rate: 165
  • Temperature: 37.2°C
  • Respiratory rate: 32
• The patient has been titrated with NorEpi 10ug/min and has undergone Atrovent neb and suctioning of secretions.

Shock Management

• Shock is a state of acute circulatory failure leading to decreased organ perfusion, with inadequate delivery of oxygenated blood to tissues and resultant end-organ dysfunction 3.
• The mechanisms that can result in shock are divided into 4 categories: hypovolemic, distributive, cardiogenic, and obstructive 3, 4.
• Vasopressors, such as norepinephrine, are commonly used to manage shock, particularly in cases of distributive shock 5, 6, 7.
• Norepinephrine is the first-choice vasopressor in vasodilatory shock after adequate volume resuscitation 5.

Vasopressor Therapy

• Vasopressors bind to adrenergic receptors, inducing vasoconstriction and increasing blood pressure 5, 6.
• The choice and dose of vasopressors vary depending on the patient and physician practice 5.
• Adverse effects of vasopressors include excessive vasoconstriction, organ ischemia, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias 5.
• Vasopressin may be used as an alternative to norepinephrine in distributive shock, with some studies suggesting faster time to shock reversal and lower mortality 7.