CVS 常用藥物概論

CVS CVS 常用藥物概論常用藥物概論Yeh Yu ChangYeh Yu Chang

94.06.04.94.06.04.

分類分類

Inotropes: Inotropes: 強心強心 Chronotropic: Chronotropic: 增快心律增快心律 Pressors: Pressors: 升壓升壓 Vasodilator: Vasodilator: 降壓降壓 Antiarrhytmic agents:Antiarrhytmic agents: 抗心律不整抗心律不整

常用藥物常用藥物 Bosmine (Epinephrine)Bosmine (Epinephrine) Levophed (Norepinephrine)Levophed (Norepinephrine) DopamineDopamine DobutamineDobutamine Primacor (Milrinone) Primacor (Milrinone) IsuprelIsuprel NTGNTG Nitroglyceride Nitroglyceride PerdipinePerdipine Amiodarone Amiodarone PGE1PGE1 DDAVPDDAVP

Cardiovascular AnatomyCardiovascular Anatomy

CONTRACTILITYHEART RATERhythm

PRELOAD AFTERLOAD

L/MinCARDIACOUTPUT

(CI=CO/m²)

CatecholaminesCatecholamines

NaturalNatural Norepinephrine: Norepinephrine: , , 11

Epinephrine: Epinephrine: , , Dopamine: D, Dopamine: D, 11, , 11 (also some NE release) (also some NE release)

SyntheticSynthetic Isoproterenol: Isoproterenol: Dobutamine: Dobutamine: 1 1 (and mix of (and mix of 22 stimulation stimulation

and and 1 1 inhibition and stimulation) inhibition and stimulation)

NE E ISO

EpinephrineEpinephrine 0.1-1 μg/kg/min0.1-1 μg/kg/min1mg in 20 ml 1mg in 20 ml 5 mg / 100 ml5 mg / 100 ml50 kg – 0.167 μg/kg/min50 kg – 0.167 μg/kg/min

DopamineDopamine 1-20 (50) μg/kg/min1-20 (50) μg/kg/min 400 mg in 250 mL400 mg in 250 mL160 mg/ 100 ml 160 mg/ 100 ml

DobutamineDobutamine 1-20 (30) μg/kg/min1-20 (30) μg/kg/min 250 mg in 100 ml250 mg in 100 ml

Isuprel Isuprel 0.02-0.15 μg/kg/min0.02-0.15 μg/kg/min 0.2 mg in 20 ml 0.2 mg in 20 ml

1 mg /100 ml1 mg /100 ml

LevophedLevophed 0.04-0.4 μg/kg/min0.04-0.4 μg/kg/min 4mg in 50 ml adult4mg in 50 ml adult

1mg in 50 ml child1mg in 50 ml child

PrimacorPrimacorIV loading 50ug/kg over IV loading 50ug/kg over 10min10minMaintenance 0.375-0.75 Maintenance 0.375-0.75 μg/kg/minμg/kg/min

10 mg in 10 ml 10 mg in 10 ml

50 kg – 15 ml/h run 50 kg – 15 ml/h run 10 min then 1 ml/h10 min then 1 ml/h

NTGNTG 0.1-4 0.1-4 μg/kg/minμg/kg/min5 mg in 10 ml5 mg in 10 ml

50 mg in 100 ml50 mg in 100 ml

NitroglycerideNitroglyceride 0.25-10 0.25-10 μg/kg/minμg/kg/min

Perdipine Perdipine 0.5 – 15 mg/h0.5 – 15 mg/h 1mg/1ml1mg/1ml

AmiodaronAmiodaronee

AdultAdultIV 150mg over 10minIV 150mg over 10minthen 1mg/min for 6hrthen 1mg/min for 6hrthen 0.5mg/min for 18 hrthen 0.5mg/min for 18 hr

3 amp in 30 ml3 amp in 30 mlRun 60 ml/h for 10 minRun 60 ml/h for 10 minThen 4 ml/h for 6 hThen 4 ml/h for 6 hThen 2 ml/h for 18 hThen 2 ml/h for 18 h

Child Child 5 mg/kg loading 5 mg/kg loading then 5-15 then 5-15 μg/kg/minμg/kg/min

1/2 amp in 15 ml 1/2 amp in 15 ml

PGE 1 PGE 1 25-250 25-250 ngng/kg/min /kg/min 20 μg/powder20 μg/powderoror500μg/ml500μg/ml

DDAVPDDAVP 0.3 μg/kg dilute in 50 0.3 μg/kg dilute in 50 ml NS over 100 ml/hml NS over 100 ml/h

4 μg/ml4 μg/ml50 kg need 15 μg50 kg need 15 μg4 vial in 50 ml run 104 vial in 50 ml run 100 ml/h 0 ml/h 80 kg need 24 μg80 kg need 24 μg6 vial in 50 ml run 106 vial in 50 ml run 100 ml/h 0 ml/h

μg/kg/minμg/kg/min

160 mg in 100 ml, 50 kg (mg/ml)160 mg in 100 ml, 50 kg (mg/ml) 160*160*10001000 : mg/ml → μg/ml : mg/ml → μg/ml 160 * 160 * 10001000//100100 : 100ml → 1ml : 100ml → 1ml 160 *1000/100/160 *1000/100/6060 : μg/h → μg/min : μg/h → μg/min

160/6/160/6/5050 = 0.533 μg/kg/min = 0.533 μg/kg/min

Thanks for your Thanks for your attention!attention!

Have a nice weekend!Have a nice weekend!





ALPHA-ADRENERGIC ALPHA-ADRENERGIC MEDICATIONSMEDICATIONS

Can be divided into:Can be divided into: AlphaAlpha11-adrenergic effects:-adrenergic effects:

Vascular smooth muscle contractionVascular smooth muscle contraction

AlphaAlpha22-adrenergic effects:-adrenergic effects: Vascular smooth muscle relaxation--Vascular smooth muscle relaxation--

this is a very mild effect only at low this is a very mild effect only at low doses of an alpha-adrenergic agent like doses of an alpha-adrenergic agent like epinephrine.epinephrine.

BETA-ADRENERGIC BETA-ADRENERGIC MEDICATIONSMEDICATIONS

Can be divided into:Can be divided into: BetaBeta11-adrenergic effects:-adrenergic effects:

Direct cardiac effectsDirect cardiac effects Inotropy (improved cardiac Inotropy (improved cardiac

contractility)contractility) Chronotropy (increased heart rate)Chronotropy (increased heart rate)

BetaBeta22-adrenergic effects:-adrenergic effects: VasodilationVasodilation BronchodilationBronchodilation

EpinephrineEpinephrine

1 –1 –↑contractility and H.R → ↑C.O. and myoc↑contractility and H.R → ↑C.O. and myocardial oxygen demand.ardial oxygen demand.

1 –1 –↓splanchnic and renal blood flow but↑co↓splanchnic and renal blood flow but↑coronary and cerebral perfusion pressure, SBP ronary and cerebral perfusion pressure, SBP

2 – 2 – vasodilation in skeletal muscle may lower vasodilation in skeletal muscle may lower diastolic pressure also relaxes bronchial smooth diastolic pressure also relaxes bronchial smooth musclemuscle

Dopamine vs DobutamineDopamine vs Dobutamine

Selecting inotropic and vasopressor agents for specific hemodynamic disturbances in children

Hemodynamic pattern Normal Deceased Elevated

Blood pressure or SVR

Myocardial dysfunction

Dobutamine or dopamineor amrinone

Epinephrine or dopamine

(or dobutamine plusnorepinephrine)

Dobutamineplus

nitroprusside

CHF Dobutamine Primacor

Dopamine Dobutamineplus

nitroprusside

Bradycardia None Isoproterenol None

Dobutamine IndicationsDobutamine Indications

Consider for pump problems Consider for pump problems (CHF) with systolic blood (CHF) with systolic blood pressure of 70 to 100 mm Hg pressure of 70 to 100 mm Hg and and no no signs of shocksigns of shock

Dobutamine PrecautionsDobutamine Precautions Avoid with systolic blood pressure Avoid with systolic blood pressure

<100 mm Hg <100 mm Hg and and signs of shocksigns of shock May cause tachyarrhythmias, May cause tachyarrhythmias,

fluctuations in blood pressure, fluctuations in blood pressure, headache, and nauseaheadache, and nausea

Contraindication:Contraindication: Suspected or Suspected or known poison/drug-induced shockknown poison/drug-induced shock

Do not mix with sodium Do not mix with sodium bicarbonate.bicarbonate.

Dobutamine IV InfusionDobutamine IV Infusion Usual infusion rate: 2 to 20 µg/kg Usual infusion rate: 2 to 20 µg/kg

/min/min Titrate so heart rate does not Titrate so heart rate does not

increase by >10% of baselineincrease by >10% of baseline Hemodynamic monitoring is Hemodynamic monitoring is

recommended for optimal userecommended for optimal use

DopamineDopamine IndicationsIndications

22ndnd drug for symptomatic drug for symptomatic bradycardia after atropinebradycardia after atropine

Use for hypotension (systolic Use for hypotension (systolic blood pressure = 70 - 100 mm blood pressure = 70 - 100 mm Hg) with signs and symptoms of Hg) with signs and symptoms of shockshock

Dopamine PrecautionsDopamine Precautions

May use in patients with hypovolemia May use in patients with hypovolemia but only after volume replacementbut only after volume replacement

Use with caution in cardiogenic shock Use with caution in cardiogenic shock with accompanying congestive heart with accompanying congestive heart failurefailure

May cause tachyarrhythmias, May cause tachyarrhythmias, excessive vasoconstrictionexcessive vasoconstriction

Taper slowly.Taper slowly. Do not mix with sodium bicarbonate Do not mix with sodium bicarbonate

Dopamine Continuous Dopamine Continuous InfusionsInfusions

Titrate to patient response:Titrate to patient response: Low DoseLow Dose

1 to 5 µg/kg per minute (“renal doses)1 to 5 µg/kg per minute (“renal doses) Moderate DoseModerate Dose

5 to 10 µg/kg per minute (“cardiac 5 to 10 µg/kg per minute (“cardiac doses”)doses”)

High DoseHigh Dose 10 to 20 µg/kg per minute (“pressor 10 to 20 µg/kg per minute (“pressor

doses”)doses”)

Epinephrine Epinephrine IndicationsIndications

Cardiac arrest: Cardiac arrest: VF, pulseless VT, asystole, PEAVF, pulseless VT, asystole, PEA

Symptomatic bradycardia: Symptomatic bradycardia: After atropine, dopamine and TCPAfter atropine, dopamine and TCP

Severe hypotension,Severe hypotension, Anaphylaxis: Anaphylaxis: Combine with large fluid volumes, Combine with large fluid volumes,

corticosteroids, antihistaminescorticosteroids, antihistamines

EpinephrineEpinephrine PrecautionsPrecautions

Raising BP and increasing HR may cause Raising BP and increasing HR may cause myocardial ischemia, anginamyocardial ischemia, angina

High doses do not improve survival or neHigh doses do not improve survival or neurologic outcome and may contribute to urologic outcome and may contribute to postresuscitation myocardial dysfunctionpostresuscitation myocardial dysfunction

Higher doses Higher doses may may be required to treat poibe required to treat poison/drug-induced shockson/drug-induced shock

Epinephrine in Cardiac Epinephrine in Cardiac ArrestArrest

IV Dose: IV Dose: 1 mg (10 mL of 1:10 000 1 mg (10 mL of 1:10 000 solution) administered every 3 to 5 solution) administered every 3 to 5 minutes during resuscitationminutes during resuscitation

Follow each dose with 20 mL IV flush.Follow each dose with 20 mL IV flush. ETT: ETT: 2 to 2.5 mg (1:1000) diluted in 2 to 2.5 mg (1:1000) diluted in

10 mL normal saline.10 mL normal saline.

Isoproterenol Isoproterenol IndicationsIndications

Use cautiously as Use cautiously as temporizing temporizing measure if measure if external pacer is not external pacer is not available available for treatment of for treatment of symptomatic bradycardiasymptomatic bradycardia

Refractory torsades unresponsive to Refractory torsades unresponsive to MgSOMgSO44

Temporary Temporary control of bradycardia in control of bradycardia in heart transplant patientsheart transplant patients

Poisoning from ß-adrenergic blockersPoisoning from ß-adrenergic blockers

Isoproterenol Isoproterenol PrecautionsPrecautions

Do not use for treatment of cardiac arrestDo not use for treatment of cardiac arrest Increases myocardial oxygen requirementsIncreases myocardial oxygen requirements Do not give with epinephrine; can cause Do not give with epinephrine; can cause

VF/VTVF/VT Do not administer with poison/drug induced Do not administer with poison/drug induced

shock (exception: ß-blocker poisoning)shock (exception: ß-blocker poisoning) Higher doses are Class III (harmful) except Higher doses are Class III (harmful) except

for ß-adrenergic blocker poisoningfor ß-adrenergic blocker poisoning

Isoproterenol IV Isoproterenol IV InfusionInfusion

Infuse at 2 to 10 µg/minInfuse at 2 to 10 µg/min Titrate to adequate heart rateTitrate to adequate heart rate In torsades, titrate to increase In torsades, titrate to increase

heart rate until VT is suppressedheart rate until VT is suppressed

Lidocaine IndicationsLidocaine Indications

Cardiac arrest from VF/VTCardiac arrest from VF/VT Stable VT, wide-complex Stable VT, wide-complex

tachycardias of uncertain type, tachycardias of uncertain type, wide-complex PSVT (Class wide-complex PSVT (Class Indeterminate)Indeterminate)

Lidocaine PrecautionsLidocaine Precautions

Prophylactic Prophylactic use in AMI patients is use in AMI patients is not not recommendedrecommended

Reduce maintenance dose (not Reduce maintenance dose (not loading dose) in presence of loading dose) in presence of impaired liver function or left impaired liver function or left ventricular dysfunctionventricular dysfunction

Discontinue infusion immediately Discontinue infusion immediately if signs of toxicity developif signs of toxicity develop

Lidocaine inLidocaine inCardiac Arrest From Cardiac Arrest From

VF/VTVF/VT Initial dose: 1 to 1.5 mg/kg IVInitial dose: 1 to 1.5 mg/kg IV For refractory VF may give For refractory VF may give

additional 0.5 to 0.75 mg/kg IV additional 0.5 to 0.75 mg/kg IV push, repeat in 5 to 10 minutes; push, repeat in 5 to 10 minutes; maximum total dose: 3 mg/kg.maximum total dose: 3 mg/kg.

ETT: 2 to 4 mg/kg.ETT: 2 to 4 mg/kg.

LidocaineLidocaine

Perfusing ArrhythmiaPerfusing Arrhythmia For stable VT, wide-complex tachycardia For stable VT, wide-complex tachycardia

of uncertain type, significant ectopy: of uncertain type, significant ectopy: 1 to 1.5 mg/kg IVP1 to 1.5 mg/kg IVP

Repeat 0.5 to 0.75 mg/kg every 5 to 10 Repeat 0.5 to 0.75 mg/kg every 5 to 10 minutesminutes

Maximum total dose: 3 mg/kg.Maximum total dose: 3 mg/kg.

Maintenance InfusionMaintenance Infusion 2 to 4 mg/min2 to 4 mg/min

Magnesium Sulfate Magnesium Sulfate IndicationsIndications

Cardiac arrest only if torsades de Cardiac arrest only if torsades de pointes or suspected pointes or suspected hypomagnesemia is presenthypomagnesemia is present

Refractory VF (after lidocaine)Refractory VF (after lidocaine) Torsades de pointes with a pulseTorsades de pointes with a pulse Life-threatening ventricular Life-threatening ventricular

arrhythmias due to digitalis arrhythmias due to digitalis toxicitytoxicity

Magnesium Sulfate Magnesium Sulfate PrecautionsPrecautions

Occasional fall in blood pressure Occasional fall in blood pressure with rapid administration.with rapid administration.

Use with caution if renal failure is Use with caution if renal failure is present.present.

Magnesium Sulfate Magnesium Sulfate AdministrationAdministration

Cardiac Arrest (for hypomagnesemia or TdP)Cardiac Arrest (for hypomagnesemia or TdP) 1 to 2 g (2 to 4 mL of a 50% solution) diluted i1 to 2 g (2 to 4 mL of a 50% solution) diluted i

n 10 mL of D5W IVPn 10 mL of D5W IVP Torsades de Pointes (not in cardiac arrest)Torsades de Pointes (not in cardiac arrest) Loading dose of 1 to 2 g mixed in 50 to 100 mLoading dose of 1 to 2 g mixed in 50 to 100 m

L of D5W, over 5 to 60 minutes IVL of D5W, over 5 to 60 minutes IV Follow with 0.5 to 1 g/h IV (titrate dose to conFollow with 0.5 to 1 g/h IV (titrate dose to con

trol the torsades)trol the torsades)

Nitroglycerin Nitroglycerin IndicationsIndications

Initial antianginal for suspected ischemic Initial antianginal for suspected ischemic painpain

For initial 24 to 48 hours in patients with For initial 24 to 48 hours in patients with AMI and CHFAMI and CHF, large anterior wall infarction, , large anterior wall infarction, persistent or recurrent ischemia, or persistent or recurrent ischemia, or hypertensionhypertension

Continued use (beyond 48 hours) for Continued use (beyond 48 hours) for patients with recurrent angina or patients with recurrent angina or persistent pulmonary congestionpersistent pulmonary congestion

Hypertensive urgency with ACSHypertensive urgency with ACS

NitroglycerinNitroglycerinPrecautions/Precautions/

ContraindicationsContraindications Limit normotensive BP drop to 10% Limit normotensive BP drop to 10% Limit hypertensive BP drop to 30% Limit hypertensive BP drop to 30% Avoid BP drop below 90 mm HgAvoid BP drop below 90 mm Hg Do not mix with other drugsDo not mix with other drugs Sit or lie pt down when receiving medSit or lie pt down when receiving med Do not shake aerosol spray (affects metered Do not shake aerosol spray (affects metered

dose)dose)ContraindicationsContraindications HypotensionHypotension Severe bradycardia or severe tachycardiaSevere bradycardia or severe tachycardia RV infarctionRV infarction Viagra within 24 hoursViagra within 24 hours

Nitroglycerin Nitroglycerin AdministrationAdministration

IV Bolus/InfusionIV Bolus/Infusion IV bolus: 12.5 to 25 µgIV bolus: 12.5 to 25 µg Infuse at 10 to 20 µg/minInfuse at 10 to 20 µg/min Route of choice for emergenciesRoute of choice for emergencies Titrate to effectTitrate to effectSublingual RouteSublingual Route 1 tablet (0.3 to 0.4 mg); repeat every 5 1 tablet (0.3 to 0.4 mg); repeat every 5

minutes.minutes.Aerosol SprayAerosol Spray Spray for 0.5 to 1 second at 5-minute Spray for 0.5 to 1 second at 5-minute

intervals (provides 0.4 mg per dose).intervals (provides 0.4 mg per dose).

Nitroprusside Nitroprusside IndicationsIndications

Hypertensive crisis.Hypertensive crisis. To reduce afterload in heart To reduce afterload in heart

failure and acute pulmonary failure and acute pulmonary edemaedema

To reduce afterload in acute To reduce afterload in acute mitral or aortic valve mitral or aortic valve regurgitationregurgitation

Nitroprusside Nitroprusside PrecautionsPrecautions

Light-sensitive; therefore, wrap drug reservoiLight-sensitive; therefore, wrap drug reservoir in aluminum foilr in aluminum foil

May cause hypotension, thiocyanate toxicity, May cause hypotension, thiocyanate toxicity, and COand CO2 2 retention.retention.

May reverse hypoxic pulmonary vasoconstricMay reverse hypoxic pulmonary vasoconstriction in patients with pulmonary disease, exaction in patients with pulmonary disease, exacerbating intrapulmonary shunting, resulting ierbating intrapulmonary shunting, resulting in hypoxemian hypoxemia

Other side effects include headaches, nauseaOther side effects include headaches, nausea, vomiting, and abdominal cramps , vomiting, and abdominal cramps

Nitroprusside IV Nitroprusside IV InfusionInfusion

Begin at 0.1 µg/kg per minute and Begin at 0.1 µg/kg per minute and titrate upward every 3 to 5 minutes titrate upward every 3 to 5 minutes to desired effect (up to 5 µg/kg per to desired effect (up to 5 µg/kg per minute).minute).

Use with an infusion pumpUse with an infusion pump Action occurs within 1 to 2 minutesAction occurs within 1 to 2 minutes

Norepinephrine Norepinephrine IndicationsIndications

For severe cardiogenic shock and For severe cardiogenic shock and hemodynamically significant hemodynamically significant hypotension (BP<70 mm Hg) with hypotension (BP<70 mm Hg) with low total peripheral resistancelow total peripheral resistance

This is an agent of last resort for This is an agent of last resort for management of ischemic heart management of ischemic heart disease and shockdisease and shock

Norepinephrine Norepinephrine PrecautionsPrecautions

Increases myocardial oxygen Increases myocardial oxygen requirements because it raises requirements because it raises blood pressure and heart rateblood pressure and heart rate

May induce arrhythmias. Use with May induce arrhythmias. Use with caution in patients with acute caution in patients with acute ischemia; monitor cardiac outputischemia; monitor cardiac output

Extravasation causes tissue necrosisExtravasation causes tissue necrosis If extravasation occurs, administer If extravasation occurs, administer

phentolamine 5 to 10 mg in 10 to 15 phentolamine 5 to 10 mg in 10 to 15 mL NS, infiltrated into areamL NS, infiltrated into area

Norepinephrine IV Infusion Norepinephrine IV Infusion

0.5 to 1 µg/min titrated to improve BP 0.5 to 1 µg/min titrated to improve BP (up to 30 µg/min)(up to 30 µg/min)

Do not administer in same IV line as Do not administer in same IV line as alkaline solutionsalkaline solutions

Poison/drug-induced hypotension may Poison/drug-induced hypotension may require higher doses to achieve require higher doses to achieve adequate perfusionadequate perfusion

Cardiac PhysiologyCardiac Physiology

Nervous Control Nervous Control of the Heartof the Heart SympatheticSympathetic ParasympathetiParasympatheti

cc Autonomic Autonomic

Control of the Control of the HeartHeart ChronotropyChronotropy InotropyInotropy DromotropyDromotropy

Role of Role of ElectrolytesElectrolytes

CatecholaminesCatecholamines

NaturalNatural Norepinephrine: Norepinephrine: , , 11

Epinephrine: Epinephrine: , , Dopamine: D, Dopamine: D, 11, , 11 (also some NE release) (also some NE release)

SyntheticSynthetic Isoproterenol: Isoproterenol: Dobutamine: Dobutamine: 1 1 (and mix of (and mix of 22 stimulation stimulation

and and 1 1 inhibition and stimulation) inhibition and stimulation)

NoncatecholaminesNoncatecholamines Direct-actingDirect-acting

Albuterol: Albuterol: 22

Clonidine: Clonidine: 22 Phenylephrine: Phenylephrine: 11

Mixed-acting Mixed-acting Ephedrine: Ephedrine: (CNS), (CNS), , and NE release, and NE release

Indirect-acting (effects from NE release)Indirect-acting (effects from NE release) Tyramine: Tyramine: , , 11

Amphetamine: Amphetamine: (CNS), (CNS), 11 (also DA and 5-HT (also DA and 5-HT release centrally)release centrally)

Therapeutic uses (2)Therapeutic uses (2) Cardiac stimulation (Cardiac stimulation (11, , 22))

In bradycardia: In bradycardia: dopamine, epinephrinedopamine, epinephrine In hypotension: In hypotension: dopamine,dopamine, norepinephrinenorepinephrine In normotension: In normotension: dobutaminedobutamine

Bronchial dilation (Bronchial dilation (22)) In bronchial asthma: In bronchial asthma: albuterolalbuterol In anaphylaxis: In anaphylaxis: epinephrineepinephrine

Ocular effectsOcular effects Pupillary dilation (Pupillary dilation (11): ): phenylephrinephenylephrine Glaucoma (Glaucoma (22): ): epinephrineepinephrine

CARDIOVASCULAR CARDIOVASCULAR MEDICATIONSMEDICATIONS

Main actions of most of the Main actions of most of the following cardiovascular following cardiovascular medications will be determined medications will be determined by the adrenergic effects of the by the adrenergic effects of the medications.medications.

Can either be:Can either be: alpha-adrenergicalpha-adrenergic beta-adrenergicbeta-adrenergic dopaminergic dopaminergic

CARDIAC MEDS VIA CARDIAC MEDS VIA CONTINUOUS INFUSIONCONTINUOUS INFUSION EpinephrineEpinephrine NorepinephrineNorepinephrine DopamineDopamine DobutamineDobutamine Milrinone/AmrinoneMilrinone/Amrinone Sodium NitroprussideSodium Nitroprusside NitroglycerinNitroglycerin IsoproterenolIsoproterenol

EPINEPHRINEEPINEPHRINE

Both an alpha- and beta-adrenergic Both an alpha- and beta-adrenergic agentagent

Therefore, indications for its use as Therefore, indications for its use as a continuous infusion are:a continuous infusion are: low cardiac output statelow cardiac output state

beta effects will improve cardiac functionbeta effects will improve cardiac function alpha effects may increase afterload and alpha effects may increase afterload and

decrease cardiac outputdecrease cardiac output septic shockseptic shock

useful for both inotropy and useful for both inotropy and vasoconstrictionvasoconstriction

EPINEPHRINEEPINEPHRINE Actions are dose dependent (mcg/kg/min):Actions are dose dependent (mcg/kg/min):

0.02-0.08 = mostly beta0.02-0.08 = mostly beta11 and beta and beta2 2

stimulation. stimulation. increased cardiac outputincreased cardiac output mild vasodilationmild vasodilation

0.1-2.0 = mix of beta0.1-2.0 = mix of beta1 1 andand alphaalpha11

increase cardiac outputincrease cardiac output increase SVR = vasoconstrictionincrease SVR = vasoconstriction

> 2.0 = mostly alpha> 2.0 = mostly alpha11

increase SVR, and may decrease CO by increasing increase SVR, and may decrease CO by increasing afterloadafterload

EPINEPHRINEEPINEPHRINE Side effects include:Side effects include: Anxiety, tremors,palpitationsAnxiety, tremors,palpitations Tachycardia and tachyarrhythmiasTachycardia and tachyarrhythmias Increased myocardial oxygen requirements Increased myocardial oxygen requirements

and potential to cause ischemiaand potential to cause ischemia Decreased splanchnic and hepatic Decreased splanchnic and hepatic

circulation (elevation of AST and ALT)circulation (elevation of AST and ALT) Anti-Insulin effects: lactic acidosis, Anti-Insulin effects: lactic acidosis,

hyperglycemiahyperglycemia

NOREPINEPHRINENOREPINEPHRINE

Employed primarily for its alpha Employed primarily for its alpha agonist effect - increases SVR (and agonist effect - increases SVR (and B.P.) without significantly B.P.) without significantly increasing C.O.increasing C.O.

Used in cases of low SVR and Used in cases of low SVR and hypotension such as profound hypotension such as profound “warm shock” with a normal or high “warm shock” with a normal or high C.O. stateC.O. state

Infusion rates titrated between 0.05 Infusion rates titrated between 0.05 to 1 mcg/kg/minto 1 mcg/kg/min


In general, norepinephrine differs In general, norepinephrine differs from epinephrine in that at doses from epinephrine in that at doses used in clinical practice, the used in clinical practice, the vasoconstriction outweighs any vasoconstriction outweighs any increase in cardiac output.increase in cardiac output. i.e. norepinephrine usually i.e. norepinephrine usually

increases blood pressure and SVR, increases blood pressure and SVR, often without increasing cardiac often without increasing cardiac output.output.


Side Effects:Side Effects: Similar to those of EpinephrineSimilar to those of Epinephrine Can compromise perfusion in Can compromise perfusion in

extremities and may need to be extremities and may need to be combined with a vasodilator e.g. combined with a vasodilator e.g. Dobutamine or NiprideDobutamine or Nipride

More profound effect on More profound effect on sphlancnic circulation and sphlancnic circulation and myocardial oxygen consumptionmyocardial oxygen consumption

DOPAMINEDOPAMINE

Intermediate product in the Intermediate product in the enzymatic pathway leading to the enzymatic pathway leading to the production of norepinephrine; thus, production of norepinephrine; thus, it indirectly acts by releasing it indirectly acts by releasing norepinephrine.norepinephrine.

Directly has alpha, beta and Directly has alpha, beta and dopaminergic actions which are dopaminergic actions which are dose-dependent.dose-dependent.

Indications are based on the Indications are based on the adrenergic actions desired. adrenergic actions desired.

DOPAMINEDOPAMINE

Improve renal perfusion 2-5 Improve renal perfusion 2-5 mcg/kg/minmcg/kg/min

Improve C.O. in mild to moderate Improve C.O. in mild to moderate Cardiogenic or Distributive Shock Cardiogenic or Distributive Shock 5-10mcg/kg/min5-10mcg/kg/min

Post-resuscitation stabilization in Post-resuscitation stabilization in patients with hypotension (in patients with hypotension (in conjuction with fluid therapy) 10-conjuction with fluid therapy) 10-20mcg/kg/min20mcg/kg/min

DOBUTAMINEDOBUTAMINE

Synthetic catecholamine with Synthetic catecholamine with inotropic effect (increases stroke inotropic effect (increases stroke volume) and peripheral volume) and peripheral vasodilation (decreases afterload)vasodilation (decreases afterload)

Positive chronotropic effect Positive chronotropic effect (increases HR)(increases HR)

Some lusotropic effect Some lusotropic effect Overall, improves Cardiac Output Overall, improves Cardiac Output

by above beta-agonist acitivityby above beta-agonist acitivity


Major metabolite is 3-Major metabolite is 3-OO--methyldobutamine, a potent methyldobutamine, a potent inhibitor of alpha-adrenoceptors.inhibitor of alpha-adrenoceptors. Therefore, vasodilation is possible Therefore, vasodilation is possible

secondary to this metabolite.secondary to this metabolite. Usual starting infusion rate is Usual starting infusion rate is

5 mcg/kg/min, with 5 mcg/kg/min, with the dose being titrated to effect the dose being titrated to effect up to 20 mcg/kg/min.up to 20 mcg/kg/min.


Used in low C.O. states and CHF e.g. Used in low C.O. states and CHF e.g. myocarditis, cardiomyopathy, myocarditis, cardiomyopathy, myocardial infarctionmyocardial infarction

If BP adequate, can be combined If BP adequate, can be combined with afterload reducer (Nipride or with afterload reducer (Nipride or ACE inhibitor)ACE inhibitor)

In combination with Epi/Norepi in In combination with Epi/Norepi in profound shock states to improve profound shock states to improve Cardiac Output and provide some Cardiac Output and provide some peripheral vasodilatationperipheral vasodilatation

MILRINONE/AMRINONEMILRINONE/AMRINONE

Belong to new class of agents Belong to new class of agents “Bipyridines”“Bipyridines”

Non-receptor mediated activity based on Non-receptor mediated activity based on selective inhibition of Phosphodiesterase selective inhibition of Phosphodiesterase Type III enzyme resulting in cAMP Type III enzyme resulting in cAMP accumulation in myocardiumaccumulation in myocardium

cAMP increases force of contraction and cAMP increases force of contraction and rate and extent of relaxation of rate and extent of relaxation of myocardiummyocardium

Inotropic, vasodilator and lusotropic Inotropic, vasodilator and lusotropic effecteffect

AMRINONEAMRINONE

First generation agent - limited use First generation agent - limited use now now

Long half-life (4.4 hours) with Long half-life (4.4 hours) with potential for prolonged hypotension potential for prolonged hypotension after loading doseafter loading dose

Associated with thrombocytopeniaAssociated with thrombocytopenia Dosage: Load with 0.75 mg/kg with Dosage: Load with 0.75 mg/kg with

infusion rate of 5-10 mcg/kg/mininfusion rate of 5-10 mcg/kg/min Milrinone is preferred drug from this Milrinone is preferred drug from this

groupgroup

MILRINONEMILRINONE

Increases CO by improving contractility, Increases CO by improving contractility, decreased SVR, PVR (?), lusotropic decreased SVR, PVR (?), lusotropic effect; decreased preload due to effect; decreased preload due to vasodilatation vasodilatation

Unique in beneficial effects on RV Unique in beneficial effects on RV functionfunction

Half-life is 1-2 hoursHalf-life is 1-2 hours Load with 50 mcg/kg over 30 mins Load with 50 mcg/kg over 30 mins

followed by 0.3 to 0.75 mcg/kg/minfollowed by 0.3 to 0.75 mcg/kg/min No increase in myocardial O2 No increase in myocardial O2

requirementrequirement

VASODILATORSVASODILATORS

Classified by site of actionClassified by site of action Venodilators: reduce preload - Venodilators: reduce preload -

NitroglycerinNitroglycerin Arteriolar dilators: reduce afterload Arteriolar dilators: reduce afterload

Minoxidil and HydralazineMinoxidil and Hydralazine Combined: act on both arterial and Combined: act on both arterial and

venous beds and reduce both pre- venous beds and reduce both pre- and afterload Sodium Nitroprusside and afterload Sodium Nitroprusside (Nipride)(Nipride)

NITROPRUSSIDENITROPRUSSIDE

Vasodilator that acts directly on arterial Vasodilator that acts directly on arterial and venous vascular smooth muscle.and venous vascular smooth muscle.

Indicated in hypertension and low Indicated in hypertension and low cardiac output states with increased cardiac output states with increased SVR.SVR.

Also used in post-operative cardiac Also used in post-operative cardiac surgery to decrease afterload on an surgery to decrease afterload on an injured heart.injured heart.

Action is immediate; half-life is short; Action is immediate; half-life is short; titratable action.titratable action.

NITROPRUSSIDENITROPRUSSIDE

Toxicity is with cyanide, one of the Toxicity is with cyanide, one of the metabolites of the breakdown of metabolites of the breakdown of nipride.nipride.

Severe, unexplained metabolic Severe, unexplained metabolic acidosis might suggest cyanide acidosis might suggest cyanide toxicity.toxicity.

Dose starts at 0.5 mcg/kg/min and Dose starts at 0.5 mcg/kg/min and titrate to 5 mcg/kg/min to desired titrate to 5 mcg/kg/min to desired effect. May go higher (up to 10 effect. May go higher (up to 10 mcg/kg/min) for short periods of time.mcg/kg/min) for short periods of time.

NITROGLYCERINNITROGLYCERIN Direct vasodilator as well, but the Direct vasodilator as well, but the

major effect is as a venodilator with major effect is as a venodilator with lesser effect on arterioles.lesser effect on arterioles.

Not as effective as nitroprusside in Not as effective as nitroprusside in lowering blood pressure.lowering blood pressure.

Another potential benefit is relaxation Another potential benefit is relaxation of the coronary arteries, thus of the coronary arteries, thus improving myocardial regional blood improving myocardial regional blood flow and myocardial oxygen demand.flow and myocardial oxygen demand.

NITROGLYCERINNITROGLYCERIN

Used to improve myocardial Used to improve myocardial perfusion following cardiac perfusion following cardiac surgerysurgery

Dose ranges from 0.5 to 8 Dose ranges from 0.5 to 8 mcg/kg/min. Typical dose is 2 mcg/kg/min. Typical dose is 2 mcg/kg/min for 24 to 48 hours mcg/kg/min for 24 to 48 hours post-operativelypost-operatively

Methemoglobinemia is potential Methemoglobinemia is potential side effectside effect

ISOPROTERENOLISOPROTERENOL

Synthetic catecholamineSynthetic catecholamine Non-specific beta agonist with Non-specific beta agonist with

minimal alpha-adrenergic effects.minimal alpha-adrenergic effects. Causes inotropy, chronotropy, and Causes inotropy, chronotropy, and

systemic and pulmonary systemic and pulmonary vasodilatation.vasodilatation.

Indications: bradycardia, decreased Indications: bradycardia, decreased cardiac output, bronchospasm cardiac output, bronchospasm (bronchodilator).(bronchodilator).

No longer available in some marketsNo longer available in some markets

ISOPROTERENOLISOPROTERENOL

Occasionally used to maintain Occasionally used to maintain heart rate following heart heart rate following heart transplantation.transplantation.

Dose starts at 0.01 mcg/kg/min Dose starts at 0.01 mcg/kg/min and is increased to 1.0 mcg/kg/min and is increased to 1.0 mcg/kg/min for desired effect.for desired effect.

INHALED NITRIC OXIDEINHALED NITRIC OXIDE

Selective Pulmonary vasodilatorSelective Pulmonary vasodilator Dilates only pulmonary Dilates only pulmonary

capillaries to alveoli participating capillaries to alveoli participating in gas exchangein gas exchange

Decreases intrapulmonary shunt Decreases intrapulmonary shunt and improves V/Q matchingand improves V/Q matching

Rapidly inactivated by Hgb in Rapidly inactivated by Hgb in pulm. cap. so no systemic side pulm. cap. so no systemic side effects (eg hypotension)effects (eg hypotension)

INHALED NITRIC OXIDEINHALED NITRIC OXIDE

Potential for use in ARDS and Potential for use in ARDS and Pulmonary HypertensionPulmonary Hypertension

Currently only approved for use in Currently only approved for use in neonatal Pulmonary Hypertensionneonatal Pulmonary Hypertension

ExpensiveExpensive Special monitoring equipment Special monitoring equipment

requiredrequired Dose: Concentration of 0.5-60 Dose: Concentration of 0.5-60

ppm in inhaled gasppm in inhaled gas

Additional considerationsAdditional considerations Mechanical ventilation and oxygen Mechanical ventilation and oxygen

therapy (to conserve CO)therapy (to conserve CO) Analgesia, anxiolysis and sedationAnalgesia, anxiolysis and sedation Electrolyte homeostasis esp Ca and MgElectrolyte homeostasis esp Ca and Mg Nutrition - avoid hypoglycemiaNutrition - avoid hypoglycemia Anemia is an “unconstitutional Anemia is an “unconstitutional

surcharge”surcharge” Last but not the least: Maintain Last but not the least: Maintain

appropriate intravascular volumeappropriate intravascular volume

Selecting inotropic and vasopressor agents for specific hemodynamic disturbances in children

Hemodynamic pattern Normal Deceased Elevated

Blood pressure or SVR

Septic Shock Stroke index High Stroke Index low to N

None or dopamineDobutamine or dopamine

NorepinephrineDopamine or epinephrine

(or dobutamine plusnorephinephrine)

NoneDobutamine

plusnitroprusside

Cardiogenic shock Dobutamine or amrinoneor dopamine


--

Myocardial dysfunction

Dobutamine or dopamineor amrinone


(or dobutamine plusnorepinephrine)

Dobutamineplus

nitroprusside

CHF Dobutamine or dopamineor amrinone

-- Dobutamineplus

nitroprusside

Bradycardia None Isoproterenol None

DRIP FORMULA:

6 X WT. IN KG X MCG/KG/MIN = mg in 100 ml of D5W/NSML/HR

Also another way to calculate is:

ISOPROTERENOLEPINEPHRINENOREPRINEPHRINE

} 0.6 X BODY WT. IN KG = ____ MG IN 100ML 1 ML/HR WILL DELIVER 0.1 MCG/KG/MIN

DOPAMINEDOBUTAMINEAMRINONENITROPRUSSIDE

} 6 X BODY WT. IN KG = _____ MG IN 100ML 1 ML/HR WILL DELIVER 1 MCG/KG/MIN

http://cardiacsurgery.ctsnetbooks.org/content/vol2/issue2003/images/large/85fig1.jpeg

分類分類 Inotropes: agents that improve Inotropes: agents that improve

myocardial contractility and myocardial contractility and enhance stroke volumeenhance stroke volume

Pressors: agents that increase Pressors: agents that increase systemic vascular resistance and systemic vascular resistance and increase blood pressureincrease blood pressure

Chronotropic: Increase heart rateChronotropic: Increase heart rate improve relaxation during diastole improve relaxation during diastole

and decrease EDP in the ventriclesand decrease EDP in the ventricles

分類分類

強心強心 (( 升壓升壓 )) BosmineBosmine LevophedLevophed DopamineDopamine DobutamineDobutamine PrimacorPrimacor

降壓降壓 NTGNTG Nitroglyceride Nitroglyceride PerdipinePerdipine

控制心率控制心率 Amirodarone Amirodarone IsuprelIsuprel

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CVS 常用藥物概論