Critical Care Pharmacology

Question 1

Vasoconstrictors

Answer 1

-Increases BP
-Increases afterload (some of them less than others)
-Constrict
-Limb ischemias can be affected
-can have more dysrrhythmias

Question 2

Inotropes

Answer 2

-Increases CO (contractility)
-Can cause more dysthymias
-Elevated lactates
-Can cause hotn/htn

Question 3

Vasodilators

Answer 3

-Decrease BP
-Dilate
-Decreases Afterload (some more than others)

Question 4

Complications of vasodilators

Answer 4

-cerebral vasodilation and an increase in intracranial pressure (ICP)
-increased intrapulmonary shunt due to ablation of hypoxic pulmonary vasoconstriction, evidence of platelet dysfunction fromin vitrostudies,
-activation of the sympathetic nervous system with reflex tachycardia, rebound hypertension with discontinuation of its administration

Question 5

Cardiac Output

Answer 5

-Preload (filling)
-Contractility
-Afterload (resistance to systolic ejection)—effects with htn, valvular stenosis
-SV X HR = CO

Question 6

Alpha 1

Answer 6

-Constriction on arteries and veins

Question 7

Alpha 2

Answer 7

-Presynaptic terminal inhibition

Question 8

Beta 1

Answer 8

-Increased HR, conductivity, automacitity, contractility of the heart

Question 9

Beta 2

Answer 9

-Bronchodilation of lungs
-Dilation of arterioles

Question 10

Dopaminergic

Answer 10

-Vasodilation
-effects on the kidney

Question 11

Corticosteroids

Answer 11

-One of most controversial topics in management of sepsis
-Multiple studies have revealed there’s no benefit or harm
-Don’t need to do stim test just do it
-Rapidly wean over period of days
-When in doubt “stress em out”
-About a week, nice taper

Question 12

Vitamin C

Answer 12

-Cellular antioxidant
-Cofactor in catecholamine synthesis
-Catecholamine augmentation
-Acute Vit C deficiency common in sepsis
-Hydrocortisone-synergistic with vit c
-thiamine def-reduce hyper-oxalosis risk w/ high dose vit C

Question 13

Epinephrine Action

Answer 13

-Action on a1, a2, b1, b2 agonist
-1-3mcg/min=B
-3-10 mcg/min=B and a
-10+mcg= a and B
-Increase the HR more as dose increases
-Considered an inotrope = increased contractlity most significantly
-Increases preload
-At 10+ mcg/min will increase SVR & PVR otherwise doesn’t not have much affect on SVR at lower doses
-Increases BP
-Increases CO at lower doses, 10+ mcg/min will decrease CO

Question 14

Indications for Epinephrine

Answer 14

-Cardiac Arrest
-Anaphylaxis
-Cardiogenic shock
-Bronchospasm
-Reduced CO
-Hypotension

Question 15

Dopamine Indications

Answer 15

-Low CO
-Low SVR
-Renal insufficiency?

Question 16

Dopamine Action

Answer 16

-α1, β1, β2, D1 agonist
-Indirect NE release
-1-3μg/kg/min = D1
-3-10 = β1,β2>D1
-10+ = α1>β, D
-Will increase HR at larger doses
-Increases contractality more with increased doses
-Increases preload
-Higher doses will increase SVR and PVR
-CO will increase as well as BP
-2-20 mcg/kg/min infusion

Question 17

Dobutamine Indications

Answer 17

-Low CO (esp with ↑SVR)
-Right heart failure
-Stress Echocardiography

Question 18

Dobutamine Action

Answer 18

-Strong β1> β2
-Weak α1
-Increases HR and Contractility and CO
-No affect with preload
-Could increase SVR & PVR in B-blocked patients
-BP varies (generally increases)
- 2-30 mcg/kg/min (never seen it >6mcg/kg/min) infusion
-Considered iontrope

Question 19

Milrinone Indications

Answer 19

-Low CO (esp with ↑SVR)
-Right heart failure
-Pulm HTN
-Supplement β-agonists
-Reduced proarrhythmic effect

Question 20

Milrinone Action

Answer 20

-Inhibits Phosphodiesterase III
-Increases cAMP
-Doesn’t act at β receptors
-Increased contractility
-Decreased PVR/SVR
-Increases contractility & CO
-Lowers preload
-Varies with Bp
-0.375-0.75mcg/kg/min

Question 21

Ca Chloride/Gluconate

Answer 21

-Action: Free Ca Ion
-Increases contractility, SVR/PVR
-Indications: Hypocalcemia, hypokalemia, hotn from hypocalcemia, CCB, or protamine, anesthetic overdose, counter act hypermagnesemia
-1-2g IVP

Question 22

Phenylephrine Indications

Answer 22

-Peripheral vasodilation
-Low SVR
-SVT (Reflex vagal stim)
-TET spell
-10-150 mcg/min

Question 23

Phenylephrine Action

Answer 23

-A1 agonist
-Reflex tachycardia
-No difference on contractility, preload and indifference with CO
-Increases SVR/PVR, BP
-10mg/10mL or 100mcg/1mL in codes

Question 24

Norepinephrine Action

Answer 24

-α1, α2, β1 agonist
-Intense α1 and α2 constriction throughout dosing range
-Variable affect on HR
-Increases contractility, preload, SVR/PVR, BP and medium to CO

Question 25

Norepinephrine Indications

Answer 25

-Peripheral vascular collapse
-Shock, vasoplegia
-↓SVR
-Need ↑SVR with some ↑Con
-Phenylephrine isn’t working
-2-20 mcg/min some come in mcg/kg/min

Question 26

Vasopressin Action

Answer 26

-Direct vasoconstriction via V1 receptors
-No action on β or α receptors
-No affect on HR, Contractility, preload
-Variable with CO
-Increases BP
-Increases SVR, decreases PVR?

Question 27

Vasopressin Indication

Answer 27

-Alt to Epi in Cardiac arrest
-Secondline agent:
Shock, vasoplegia, sepsis,
↓SVR
-Pulm HTN with ↓SVR?
-Physiologic dose with Milrinone
-To reduce Norepi dose
-0.01-0.06U/min
-Bolus 40U IV for VF arrest

Question 28

Methylene Blue Action

Answer 28

-Complex mechanism
-Inhibits NO/cGMP
-Inhibits NO synthase
-Increases SVR/PVR
-Increases BP
-Not first line
-Bolus 1.5-2.0mg/kg over 15-30 min
-Infusion 0.25-1.0 mg/kg/hr

Question 29

Nitroglycerin Action

Answer 29

-Direct vasodilator
↑cGMP production
-Venous>Arterial
-Excellent coronary effects
-Reflex contractility and HR
-Decreases Preload (don’t give to inferior MIs)
-Decreases SVR/PVR
-Decreases BP

Question 30

Nitroglycerin Indication

Answer 30

-Myocardial ischemia
-Increase coronary perfusion
-Relieve coronary spasm
-Hypertension
-Arterial dilation (high dose)
-Pulmonary HTN
-CHF
-40-80 mg IV bolus
-10-200 mcg/min infusion

Question 31

Nitroprusside Action

Answer 31

-Direct vasodilator
↑cGMP production
-Arterial=Venous
-Reflex effect on HR and Contractility
-Decreases preload, SVR/PVR, BP

Question 32

Nitroprusside Indications

Answer 32

HTN, ↑SVR
Controlled hypotension
↓SVR>↓Preload at lower dose
-0.1-2.0mcg/kg/min infusion
-Avoid >2.0 d/t toxicity
-protect from light
-use with caution in liver and kidney disease
-Taper infusion gradually

Question 33

Clevidipine Action

Answer 33

-CCB vasodilator
-No affect on HR, contractility
-Decreases preload, SVR/PVR

Question 34

Clevidipine Indications

Answer 34

HTN, ↑SVR
Controlled hypotension
↓SVR>↓Preload at lowerdose
-Maintenance: 4-6 mg/hr; not to exceed 21 mg/hr(1000 mL within 24 hour period)

Question 35

Angiotensin II

Answer 35

-Effective in increases MAP
-Adverse effect monitoring
-Dosing and duration limitation (be careful on running too long)

Question 36

Hydrococolbalmin (Cyanokit)

Answer 36

-Hydroxylated, active form of vitamin B12
-Nitric oxide scavenger
-FDA approval: treatment of Cyanide poisoning
5 g in 200 mL 0.9% NaCl
-Infusion over 15 minutes or 6 hours
-Suggestive data for utility in refractory vasoplegia
-Remains in bloodstream and urine days to weeks
-Interferes with labs and urinalysis

Question 37

Alpha 1 Agonists

Answer 37

-Mainly present in smooth muscle of blood vessels and muscle tissues of the heart
-Cause blood vessels to constrict

Question 38

Shock Management

Answer 38

-Treat underlying cause
-Fluid Resuscitation
-Vasopressor monotherapy&raquo_space;
-Treat w/ contributing pathophysiology
-Combo vasopressor
-Trial steroids, and adjunctive agents (thiamine, vit c)
-Novel vasopressor therapy (Angiotensin II)
-Rescue therapies (Methylene blue, cyanokit)