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Table 1 Survey questions on inotropic use

From: Current use of inotropes in circulatory shock

 

Frequency of response

Percentage of response

What is your first-line inotrope to increase cardiac pump function?

 Dobutamine

706

84%

 Dopamine

37

4%

 Dopexamine

1

0.1%

 Levosimendan

38

5%

 Milrinone or any other phosphodiesterase inhibitor

57

7%

What are your most important criteria for using an inotrope to increase cardiac pump function?

 I measure CO and find it low (e.g., cardiac index < 2.5 L min−1 m−2)

189

23%

 I measure central venous oxygen saturation and find it low (< 70%)

47

6%

 I measure left ventricular ejection fraction and find it low (< 45%)

54

6%

 There are persistent clinical signs of hypoperfusion (e.g., skin mottling, low urine output) or persistent hyperlactatemia despite a supposed adequate use of fluids and vasopressors

184

22%

 There are persistent clinical signs of hypoperfusion (e.g., skin mottling, low urine output) or persistent hyperlactatemia despite a supposed adequate use of fluids and vasopressors in the context of low left ventricular ejection fraction

365

44%

What are your primary therapeutic targets when using an inotrope?

 A normal lactate level

155

18%

 A normal veno-arterial PCO2 difference (< 6 mmHg)

37

4%

 An adequate CO

372

44%

 An adequate ScvO2

173

21%

 An adequate urine output

102

12%

When the patient does not respond to your current inotropic therapy, what is your main reason for adding another inotrope/vasoactive agent to the current therapy?

 Although the maximum dose of the 1st choice inotrope has not been reached, previous increases in the inotrope dose were ineffective

129

15%

 By adding a second inotrope although the maximum dose of the 1st choice inotrope has not been reached, I want to limit/reduce the side effects of the first inotrope

193

23%

 I suppose that the mechanism of action of the first inotrope is exhausted (e.g., adrenoceptors down regulation) and want to use a second one with an independent mechanism of action

195

23%

 I want to use synergistic effects of two different mechanisms of action

233

28%

 The maximum dose of the 1st choice inotrope has been reached

89

11%

Which of the following statements fits best your opinion on catecholamine use in the treatment of shock?

 Although epinephrine (EPI) has the same adrenoceptors profile than the combination norepinephrine (NOR) plus dobutamine (DOB), the combination NOR plus DOB should be preferred since either component can be titrated individually

372

44%

 Although EPI has the same adrenoceptors profile than the combination NOR plus DOB, EPI should be preferred because of its easiness to be used (single agent)

50

6%

 The combination NOR plus DOB should be preferred over EPI due to a better patient outcome

95

11%

 The combination NOR plus DOB should be preferred over EPI since EPI may decrease regional blood flow, particularly in the splanchnic circulation

131

16%

 The combination NOR plus DOB should be preferred over EPI since EPI may increase blood lactate levels and cause cardiac arrhythmias

191

23%

Which of the following statements fit(s) best your opinion on the use of phosphodiesterase (PDE)-inhibitors in the critically ill?

 Because of their prominent vasodilatory effect on the pulmonary circulation, PDE-inhibitors should be preferred in the treatment of predominant right heart failure

365

43%

 Compared to pure vasodilators (e.g., nitroprusside), PDE-inhibitors cause larger increases in CO and smaller decreases in arterial pressure

191

23%

 Compared to ß-adrenoceptor agonists (e.g., dobutamine), PDE-inhibitors have similar effects on CO but additionally decrease the cardiac filling pressures (CVP, PAOP)

162

19%

 PDE-inhibitors should be avoided in the treatment of cardiogenic shock since they are associated with increased mortality

74

9%

 PDE-inhibitors should be avoided in the treatment of cardiogenic shock since they may increase the incidence of atrial fibrillation or tachyarrhythmias

47

6%

Which of the following statements fits best your opinion on the use of levosimendan in the critically ill?

 Levosimendan is the only inotrope that does not increase myocardial oxygen demand

354

42%

 Levosimendan is also a potent vasodilator in the systemic and pulmonary circulation

269

32%

 Levosimendan is associated with an increased incidence of atrial fibrillation and ventricular ectopy

83

10%

 Levosimendan is the only inotrope that is not associated with an increased mortality

55

7%

 Levosimendan may be considered as cardioprotective, as it reduces troponin I release (pleiotropic effect)

78

9%