Inotropes

Inotropes have a role in some conditions such as sepsis, cardiogenic shock, neurogenic shock and anaphylaxis. However, they are likely to be harmful in other settings (when used in the inadequately resuscitated hypovolaemic patient for example). Exactly which inotrope in which setting is a subject of vigorous ongoing debate [39].

Consideration must be given to early intubation and ventilation in many shocked patients. Oxygen consumption can be dramatically reduced by taking over the work of breathing [10]. In septic patients, increased capillary permeability may mean that necessary fluid resuscitation leads to pulmonary oedema – a fact that is recognised more widely in the paediatric population where guidelines emphasise the need to consider intubation once fluid resuscitation exceeds 40-60ml/kg [40].

With the exception of adrenal insufficiency (Addisonian crisis) – which should be considered in all hypotensive patients where there is no apparent cause, particularly those on corticosteroids and if there is both unexplained hyponatraemia and hyperkalaemia – there is no role for steroid use in the initial resuscitation and treatment of a shocked patient.