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Inotropes and Vasopressors

Introduction to inotropes and vasopressors and their uses in different types of shock
by

Leckas Chang

on 17 December 2013

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Transcript of Inotropes and Vasopressors

Inotropes
and
Vasopressors

Inotrope and vasopressors are IMPORTANT in treatment of hypotension, especially in shock patients

Different situations may warrant the use of different drugs
Conclusion
Persistent hypotension & tissue hypoperfusion due to
cardiac dysfunction
with adequate intravascular volume & left ventricular filling pressure
Treatment choice:
Dobutamine
Add nordrenaline if MAP < 60 mmHg
Consider infusion adrenaline
Cardiogenic shock
VASOPRESSORS may be initiated earlier to avoid volume overload
Initial choice: noradrenaline
AVO
ID
phenylephrine
due to unopposed alpha activity that can result in reflex bradycardia, further worsening spinal cord injury associated bradycardia
Initial choice:
Dopamine infusion OR
Noradrenaline infusion
Add IV hydrocortisone 50 mg QID/100 mg TDS
Add infusion dobutamine if ScvO2 <70%
Consider vasopressin infusion if MAP <65 mm Hg despite adequate fluid resuscitation & high dose of vasopressors
Persistent hypotension, despite adequate fluid resuscitation, with perfusion abnormality (e.g. oliguria, mental impairment, lactic acidosis) associated with
infection
plus a
systemic inflammatory response
Target:
CVP:
Non-ventilated patients: 8 – 12 mm Hg
Ventilated patients: 12 – 15 mm Hg
MAP: >65 mm Hg
Septic shock
Significant haemorrhage activate neuroendocrine axes, releasing catecholamines & nonadrenergic stress hormones
BUT
These are no longer able to compensate persistent haemorrhage
Vasopressors are NOT RECOMMENDED in the initial stabilization
Permissive hypotension till bleeding is controlled in patients requiring emergent surgical intervention
If hypotension persists despite adequate blood & fluid resuscitation & surgical intervention, consider other aetiology & an appropriate vasopressor
Haemorrhagic shock
Haemorrhagic shock
Septic shock
Neurogenic shock
Cardiogenic shock
Adrenal Insufficiency of Critical Illness (Distributive/Endocrine shock)
Types of shock
Characterised by
inadequate tissue perfusion
, resulting in
life-threatening impairment of oxygen & nutrient delivery
Associated with
hypotension
, ultimately result in
multi-organ system failure
Causes: cardiac dysfunction, blood loss, autonomic dysregulation & sepsis
Treatment: initiate with fluid and/or blood resuscitation before vasopressors/inotropes
Shock
Acts on V1 & V2 receptors
V1 receptors (specifically V1a in vascular smooth muscle): constriction of vascular smooth muscle
V2 receptors: water reabsorption by enhancing renal collecting duct permeability
Indication: refractory shock (vasodilatory/septic)
Dose:
Bolus: 40 U
Infusion: 0.01 – 0.04 U/min
Reconstitution: 20 units in 40 ml 0.9% NS/D5%
Vasopressin
Acts on α1 receptors
↑ BP & a reflex ↓ in HR
Indication: hypotension (vagally mediated,
medication-induced)
Dose:
Bolus: 0.1 – 0.5 mg IV q10 – 15 min
Infusion: 0.4 – 9.1 mcg/kg/min
Reconstitution:
Bolus: 10 mg in 10 ml WFI
Infusion: 10 mg in 500 ml 0.9% NS/D5%
Phenylephrine
Reconstitution:
Bolus: 0.2 mg in 10 ml 0.9% NS/D5%
Infusion (heart block): 2 mg in 500 ml D5%
Infusion (shock): 1 mg in 500 ml D5%
Synthetic β-adrenergic agonist
Low affinity for α receptors
Powerful chronotropic & inotropic properties with potent systemic & mild pulmonary vasodilatory effects
↑ in stroke volume is counterbalanced by a β2-mediated drop in SVR → no effect on CO
Dose: 2 – 10 mcg/min
Indication: shock, complete heart block, overdose of β-blocker or severe bradycardia unresponsive to atropine
Isoprenaline
Dose:
Infusion: 0.01 – 0.1 mcg/kg/min
Bolus: 1 mg IV q3 – 5 min, max 0.2 mg/kg
IM (1:1000): 0.1 – 0.5 mg, max 1 mg
Reconstitution: 3 mg in 50 ml 0.9% NS/D5%
High affinity for β1, β2 & α1 receptors
More effects on
β receptors
at
low doses
but more on
α1 receptors
at
higher doses
β receptors: ↑ HR & force of contraction → ↑ CO (SBP ↑ but DBP may ↓ due to vasodilation & ↑ blood flow through skeletal muscle beds)
α1 receptors: cool pale extremities
Indication: refectory hypotension (to dopamine/ dobutamine), anaphylaxis, asthma, cardiac arrest
Strength: 1:1000 = 1 mg/ml; 1:10000 = 1mg/10ml
Adrenaline
Acts mainly on α1 receptor with few effects on β receptor
↑ blood pressure (BP) by vasoconstriction
Indication: septic shock where peripheral vasodilation may be causing hypotension
Dose: 0.01 – 1.5 mcg/kg/min (max 3.0 mcg/kg/min)
Reconstitution: 4 mg in 50 ml 0.9% NS/D5%
Noradrenaline
Acts on β1 & β2 receptors, with minimal action on α1 receptor
↑ cardiac output (CO) & ↓ afterload
Indication: cardiogenic shock
Dose: 2 – 20 mcg/kg/min (max 40 mcg/kg/min) [2.5 – 15 mcg/kg/min]
Reconstitution:
250 mg in 50 ml 0.9% NS/D5%
OR
Dilute this amount of drug (patient’s body weight x 3) in 50 ml NS/D5% so that the rate of infusion (ml/hr) is equal to the dose ordered (mcg/kg/min)
Dobutamine
Indication: hypotension
Dose: 2.0 – 20 mcg/kg/min (max 50 mcg/kg/min) [5 – 20 mcg/kg/min]
Reconstitution:
200 mg in 50 ml 0.9% NS/D5%
OR
Dilute this amount of drug (patient’s body weight x 3) in 50 ml NS/D5% so that the rate of infusion (ml/hr) is equal to the dose ordered (mcg/kg/min)
Acts on
dopaminergic
and
adrenergic
receptors depending on the dose:
0.5 – 3 mcg/kg/min
: D1 postsynaptic receptor (coronary, renal, mesenteric & cerebral beds) & D2 presynaptic receptor (vasculature & renal) → vasodilation & ↑ blood flow
3 – 10 mcg/kg/min
: β1 receptor → release of NAdr & inhibit reuptake in presynaptic sympathetic nerve terminals → ↑ cardiac contractility & chronotropy
10 – 20 mcg/kg/min
: α1 receptor → vasocontriction
Dopamine
RESUSCITATION
of seriously ill patients

Treatment of
HYPOTENSION
General
Indications
Inotrope
=
agent that increases the force of cardiac contraction

Vasopressor
=
agent that induces vasoconstriction

Both work via the autonomic nervous system (ANS) –
sympathetic nervous system
(SNS)

Receptors =
noradrenergic
(NAdr) receptors
Definition
KKM. Management Protocols in ICU. KL: KKM; 2006.
Overgaard CB, et al. Inotropes and Vasopressors: Review of Phyisology and Clinical Use in Cardiovascular Disease. Circulation 2008;118:1047-56.
Gilmore K. Pharmacology of Vasopressors and Inotropes. Anaesthesia 1999;10(4):1-2.
McAuley DF. Vasopressors and Inotropes [Internet]. GLOBALRPh; 1993 [updated 2012 Jun 25; cited 2012 Oct 21]. Available from: http://www.globalrph.com/icu-agents.htm
Vasopressor and Inotrope Usage in Shock. Orlando: Department of Surgical Education, Orlando Regional Medical Center; 2011.
Micromedex.
References
Often occurs in patients with
severe spinal cord injury
at
cervical
or high
thoracic
level
Sympathetic denervation reduces sympathetic outflow to CVS & subsequently decreases CO & SVR
Can occur at any time, from initial presentation to several weeks post injury
Neurogenic shock
Any Questions?
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