A and B are still important in a patient with circulatory failure. This is because the reason the circulation exists is to get oxygen to the cells. Airway and breathing play a vital role in this function. After that, circulation can be optimised. The use of inotropes nearly always follows the use of fluid and there is a constant cycle of re-assessment (Figure 6.4).
Fluid challenge - is the patient adequately filled?
Which is the appropriate vasoactive drug?
Inotrope challenge followed by re-assessment
Figure 6.4 Cycle of re-assessment in circulatory failure
The best inotrope or inotrope combination will vary not only between patients with the same condition but also in the same patient over the course of their illness. If there is no satisfactory response to an optimum dose of one inotrope, a different drug should be considered. Remember the things which affect cardiac output or flow:
CO = HR x SV (contractility/inotropy, preload, afterload)
and the things which affect blood pressure:
All of these variables should be considered and manipulated to get the best organ perfusion possible.
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