Exam II: Cardiovascular Drugs Flashcards by Linsley Lloyd

Endogenous catecholamines: (3)
___, ___, ___

[Sympathomimetics and agonists]

Epinephrine, norepinephrine, dopamine

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Synthetic catecholamines
___, ___

[Sympathomimetics and agonists]

Isoproterenol, dobutamine

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Synthetic noncatecholamines
___, ___, ___

[Sympathomimetics and agonists]

Ephedrine, amphetamine, phenylephrine

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Selective alpha2-adrenergic agonists
___, ___

[Sympathomimetics and agonists]

Clonidine, dexmedetomidine

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Selective beta2-adrenergic agonists
___, ___, ___
[Sympathomimetics and agonists]

Albuterol, terbutaline, ritodrine

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Cardiac stimulation (increased ___ and __, contractility, susceptibility to ectopy)

[Sympathetic NS Activation – fight or flight]

HR and BP

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Broncho___

[Sympathetic NS Activation – fight or flight]

dilation

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Vasoconstriction (decreased flow to ___, ___, ___)

[Sympathetic NS Activation – fight or flight]

skin, GI tract, renal

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Vasodilation (improved blood flow to ___)

[Sympathetic NS Activation – fight or flight]

skeletal muscle

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CNS stimulation – increased ___ (except ___)

[Sympathetic NS Activation – fight or flight]

cognition, alpha2

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Increased blood ___

[Sympathetic NS Activation – fight or flight]

sugar

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Lipolysis – breakdown of___

[Sympathetic NS Activation – fight or flight]

lipids

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Glycogenolysis – splitting up of ___ in the liver, yielding ___

[Sympathetic NS Activation – fight or flight]

glycogen, glucose

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___rate of coagulation
[Sympathetic NS Activation – fight or flight]

Increased

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Look at Table 13.2 in Nagelhout, p. 167 to see agonist, blocker, cholinergic agonists, and anticholinergic effects.

[Sympathetic NS Activation – fight or flight]

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Look at Table 13.2 in Nagelhout, p. 167 to see agonist, blocker, cholinergic agonists, and anticholinergic effects.

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Look at Table 13.2 in Nagelhout, p. 167 to see agonist, blocker, cholinergic agonists, and anticholinergic effects.

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Look at Table 13.2 in Nagelhout, p. 167 to see agonist, blocker, cholinergic agonists, and anticholinergic effects.

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Used to____ contractility or ___ vascular tone after sympathetic blockade caused by ___anesthesia

[Clinical use: Sympathomimetics]

increase, increase, regional

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Used to___ or ___blood pressure (to prevent tissue ischemia) during the time required to correct for hypovolemia or ____anesthesia

[Clinical use: Sympathomimetics]

increase or maintain, excessive inhaled

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Used to relax ___of asthmatic

[Clinical use: Sympathomimetics]

bronchoconstriction

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Used to manage ___phylaxis

[Clinical use: Sympathomimetics]

ana—

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Used to prolong ___ anesthesia
[Clinical use: Sympathomimetics]

regional

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Direct
Bind to receptors and activate them directly (___ and ___)

[Direct versus Indirect]

catecholamines and phenylephrine

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Indirect Cause the release of norepinephrine from ___sympathetic nerve endings (___) [Direct versus Indirect]

postganglionic, amphetamine

Indirect ___ the reuptake of norepinephrine to make more in circulation (___, ___) [Direct versus Indirect]

Block, cocaine, tricyclic antidepressants)

Indirect agent might not be effective if patient has a ___, or depletion of ___. [Direct versus Indirect]

denervation injury, neurotransmitter

The greater the concentration of the sympathomimetic, the ___ the number of receptors in tissues or ___response. [Tachyphylaxis]

lower, decreased

Example: Increased concentration of norepinephrine results in ___adrenergic receptors on cell membranes. [Tachyphylaxis]

fewer

Example: Chronic treatment with Albuterol (beta2 agonist) causes the number of receptors to___. [Tachyphylaxis]

decrease

Desensitization – define-- Can happen rapidly – within only ___. [Tachyphylaxis]

rapid reduction in response to hormones and neurotransmitters despite continuous exposure. hours

Down-regulation is different from desensitization in that ____ (example: rebound tachycardia)

receptors are destroyed and new receptors must be created before a return to baseline.

Catecholamines Inactivation by enzymes: (2) [Metabolism of sympathomimetics]

Monoamine oxidase (MAO) Catechol-O-methyltransferase (COMT)

Termination of effect influenced more by uptake back into ___ ___ nerve endings [Metabolism of sympathomimetics]

postganglion sympathetic

Filtration by the ___ of norepinephrine and dopamine [Metabolism of sympathomimetics]

lungs

Noncatecholamines Inactivated by ___ only - slower [Metabolism of sympathomimetics]

MAO

Catecholamines are short-lived due metabolism by ___ and ___ [Metabolism of sympathomimetics]

MAO and COMT

Both ___ and ___ stimulation Most potent alpha stimulant alpha1=alpha2; beta1=beta2 Given IV or subq (causes vasoconstriction which slows absorption) Poorly lipid soluble – lack of cerebral effects [Epinephrine]

alpha and beta

Most potent ___stimulant [Epinephrine]

alpha

alpha1=___; beta1=beta2 [Epinephrine]

alpha2, beta2

Given IV or subq (causes ___ which slows absorption) [Epinephrine]

vasoconstriction

Poorly lipid soluble – lack of ___ effects [Epinephrine]

cerebral

Uses: Used to ___absorption and ___ duration of local anesthetics [Epinephrine]

decrease, prolong

Uses: Treatment of ana___ reactions [Epinephrine]

___phylactic

Uses: Increase myocardial ___ [Epinepherine]

contractility

EpiPen 1:1000 – 0.3 to 0.5 ml = ___ to ___ mg [Epinepherine]

0.3 to 0.5

CV effects Low dose (___-___ mcg/kg/min) Beta – 1: increase ___, ___, ___, ___); Beta-2: ___ in DBP due to ___ in SVR (vasodilation in skeletal muscle vessels) [Epinephrine]

0.01-0.03, HR, BP, CO, Inotropy decrease, decrease

CV effects Moderate dose (___-___ mcg/kg/min) Beta-1: increase in ___, ___, ___, ___ (increase in venous return); increase in susceptibility to ___; mixed w Alpha [Epinephrine]

0.03-0.15, SBP, HR, CO, inotropy, arrhythmias

CV effects: Large dose (___ mcg/kg/min) both Beta and Alpha-1, but ___predominate: ___ of the skin, mucosa, and hepatorenal vessels (decreased renal blood flow), ___common [Epinephrine]

>0.15, Alpha, vasoconstriction, SVT

Net effect of the vascular changes (at low dose) is the distribution of blood flow to the ___and decreased ___, but with ___ renal blood flow. [Epinephrine]

skeletal muscle, SVR, decreased

___receptors are more sensitive to lower epinephrine doses while effects on ___ receptors predominate at higher doses. [Epinephrine]

B2, A1

At higher doses, the predominant A activity and resultant vasoconstriction leads to increased ___, which may impede ___ in CO. [Epinephrine]

afterload, increases

Increase venous return due to high concentration of receptors in ____ [Epinephrine]

venous vasculature.

Respiratory Smooth muscle relaxed in the bronchi (___) [Epinephrine]

Beta2

Respiratory However, if beta antagonist is present, the ___ effect causes bronchoconstriction. [Epinephrine]

alpha1

Metabolic most significant effect of all catecholamines – ___ [Epinephrine]

increase in blood glucose

Metabolic: Beta2 – increases ___ and ___ [Epinephrine]

glycogenolysis and lipolysis

Metabolic: Alpha2 – inhibits ___ (hyperglycemia) [Epinephrine]

release of insulin

Electrolytes Beta2 – stress induced ___ (activation of the ___ on RBCs) Initial increased K – it follows ___out of hepatic cells [Epinephrine]

hypokalemia, sodium-potassium pump glucose

Ocular ___ – contraction of the radial muscles of the iris causes ____; contraction of the ___ causing bulging of the eyes (exophthalmos) [Epinephrine]

Alpha1, pupil dilation, orbital muscles

GI/GU Relaxation of ___ ___ muscle ___ – relaxation of the ___ muscle of the bladder; ___ contracts the sphincter muscles [Epinephrine]

GI smooth, Beta, detrusor, alpha1

Coagulation is accelerated with___ – induces ___ and increases factor V activity

epi, platelet aggregation

Naturally occurring catecholamine released from ___ ___ nerve endings [Norepinephrine]

postganglionic sympathetic

Potent ___ with ___ agonist effect, but little beta___ effect [Norepinephrine]

alpha agonist, beta1, 2

alpha1___alpha2; beta1___beta2 [Norepinephrine]

=, >>

Clinical use: Vasoconstrictor to increase ___ and raise ___ [Norepinephrine]

SVR, BP

Infiltration of NE into ___ tissue can cause ___ due to vasoconstriction* [Norepinephrine]

subcutaneous, necrosis

Infiltration - ___ [Norepinephrine]

phentolamine

CV effects ___ – vasoconstriction of both ___ and ___ vessels of all vascular beds; increased ___, ___, increased* venous return and decreased HR [Norepinepherine]

Alpha1, arterial and venous, SVR, MAP

CV effects ___ – overshadowed by the above effects causing a decrease in ___, decreased ___, decreased kidney blood flow [Norepinepherine]

Beta1, CO, tissue perfusion

Respiratory – no ___effects [Norepinephrine]

beta2

Metabolic – ___ unlikely [Norepinephrine]

hyperglycemia

At higher doses, decreased___ due to constriction ___ to the capillary bed which causes___of fluid there. Also results in leakage of that fluid into the ____. [Norepinephrine]

venous return, proximal, trapping, interstitial

Lowering the dose of norepi has been shown to “decrease the ___” – studies raised the legs of the participants to obtain ___ in preload. So ___ vasoconstriction alone did not result in increased preload. [Norepinepherine]

resistance to venous return, increase, alpha1

Effects of norepinephrine on mean ___ pressure and ___ in human septic shock* [Norepinepherine]

systemic, venous return

Dose:___ mcg/kg/min [Norepinepherine]

0.02 -0.4

Low dose: ___ selective – ___ HR, inotropy [Norepinepherine]

Beta1, increase

High dose: ___, ___, ___ – ___ SVR, BP, but ___ HR (barorec. Reflex) [Norepinepherine]

Alpha1, Alpha2, Beta1, increase, decreased

Bolus –___ – ___ mcgs (intermittent boluses – less bradycardia than phenylephrine) [Norepinepherine]

DILUTE, 4-16

Ideal for ___, post ___ with ___ SVR state [Norepinepherine]

sepsis, CPB, decrease

___ in conditions like cardiogenic shock due to the NE increased afterload and myocardial oxygen demands [Norepinepherine]

AVOID

___ ___ in the nervous system (central and peripheral) [Dopamine]

Endogenous neurotransmitte

D1___D2___beta___alpha [Dopamine]

=, >>, >>

Low dose (___mcg/kg/min) – ___ renal vasodilation, may have ___ BP [Dopamine]

1-2, D1, decreased

Moderate dose (___ mcg/kg/min) – ___ in the heart (increased ___, ___, ____) [Dopamine]

2-10, beta1, HR, inotropy, CO

High dose (___ mcg/kg/min) – ___ in the peripheral vessels overrides ___ and ___ [Dopamine]

10-20, alpha1, D and Beta

Indirect ___ effect due to causing NE release via ___ stimulation [Dopamine]

sympathomimetic, beta 1

Indications Increase ___ in patients with low BP, elevated ___ filling pressures, and ___ urine output [Dopamine]

CO, atrial, low

Indications ____renal blood flow, glomerular filtration rate, excretion of ___ and ___output [Dopamine]

increase, sodium and urine

“Renal dose dopamine” – no studies have shown that dopamine decreases the incidence of ___ ___ ___ of those at risk [Dopamine]

acute renal failure

___increases, m & m do not improve [Dopamine]

UOP

Renal effects antagonized by (3): [Dopamine]

arterial hypoxemia and droperidol and metoclopramide.

Inhibits aldosterone – increase in ___ and ___ [Dopamine]

Na and UOP

CV effects ___ – increases CO; increases ___, ___, and ___ [Dopamine]

Beta1, HR, BP and SVR

CV Effects Release of norepinephrine – ___ and ___ to dysrhythmias (less than epinephrine) [Dopamine]

inotropic and susceptible

CV effects Can raise myocardial ____> O2 supply [Dopamine]

O2 demand

___ dilates renal and mesenteric vascular beds [Dopamine]

Respiratory effects Inhibits the ___ response to arterial hypoxemia [Dopamine]

ventilatory

Selective beta1; beta1___beta2____alpha [Dobutamine]

>, (>>>>)

Indication: Increase CO in patients with___ [Dobutamine]

congestive heart failure

Dose – ___ mcg/kg/min Increase ___, ___, ___ [Dobutamine]

0.5-15, HR, inotropy, CO

Combine with dopamine to improve ___ or with a vasodilator to ___and further improve CO [Dobutamine]

renal blood flow, decrease SVR

CV effects ___ – increase in CO with little increase in ___ or ___ (minimal increase in oxygen demand), decreases ___ and ___ [Dobutamine]

Beta1, HR or BP, SVR and PVR

Unlike dopamine, dobutamine is a ___ vasodilator and cannot cause renal ____. [Dobutamine]

coronary artery, vasodilation

High doses cause ___ and ___ (otherwise unlikely due to no release of ___) [Dobutamine]

increased HR and dysrhythmias, norepi

Most potent ___agonist [Isoproterenol]

beta

beta1___beta2___alpha []Isoproterenol]

=, >>>>

Indications Increase heart rate with___ ___ [Isoproterenol]

heart block

Indications Decrease pulmonary ___ ___ Bronchodilation [Isoproterenol]

vascular resistance

Indications Broncho___ [Isoproterenol]

dilation

CV effects ___ – increased HR, inotropic effect, and susceptibility to dysrhythmias [Isoproterenol]

Beta1

___– decreased SVR due to vasodilation in skeletal muscle [Isoproterenol]

Beta2

Summary – decreased ___ decreased ___, increased oxygen demand; not good for patients with____. [Isoproterenol]

MAP, coronary blood flow, oxygen demand, coronary artery disease

___ transplant patients [Isoproterenol]

Heart

Name 2 synthetic noncatecholamines

Ephedrine and phenylephrine

Indirect-acting*; stimulates ___ and ___ Effects due to release of norepinephrine and the direct effect of ephedrine on beta adrenergic receptors May be given orally, IM or IV Dose – 2.5-10 mg (must increase subsequent doses to obtain same response, tachyphylaxis) Prolonged duration as a noncatecholamine [Ephedrine]

alpha and beta

Effects due to release of ___ and the direct effect of ephedrine on____ receptors [Ephedrine]

norepinephrine, beta adrenergic

May be given: (3) [Ephedrine]

orally, IM or IV

Dose –___ mg (must ____ subsequent doses to obtain same response, ____) [Ephedrine]

2.5-10, increase, tachyphylaxis

Prolonged duration as a ___ [Ephedrine]

noncatecholamine

Tachyphylaxis – persistent presence of ___ on receptors or depletion of ___stores. [Ephedrine]

ephedrine, NE

Uses endogenous catechol stores from ___ ___nerve [Ephedrine]

presynaptic symp

Doesn’t work when ___ ___ stores are depleted or absent (sepsis or transplant) [Ephedrine]

neuronal catechol

Indications Temporarily ___ BP due to sympathetic blockade from ___ or hypotension due to___ or ___ [Ephedrine]

increase, regional, inhaled or intravenous anesthesia

Bronchodilation (___ onset) or nasal decongestant [Ephedrine]

slow

Indications: Antiemetic (___ mg/kg IM) [Ephedrine]

0.5

CV effects Similar to ___, but not as intense (___X): beta1 - increased systolic and diastolic ___, ___, ___; increased ___ is the principle effect. [Ephedrine]

epinephrine, 250, BP, HR, and CO, contractility

CV effects: ___ – vasoconstriction – ___ and ___ flow decreased [Ephedrine]

alpha1, renal and splanchnic

CV effects: ___ – vasodilation – ___ and ___ muscle vessels flow increased [Ephedrine]

beta2, coronary artery and skeletal

CV effects: SVR may not change much as ___ of some vessels offset the ___ of others [Ephedrine]

vasodilation, vasoconstriction

When beta-blockade is present, response to ephedrine might resemble ___ [Ephedrine]

alpha agonist.

Respiratory effects ___ – bronchodilation [Ephedrine]

Beta2

CNS – stimulation; increases ___; less than ___ Ocular – mydriasis Metabolic – no hyperglycemia Uterine blood flow – NOT* the “drug of choice” - higher incidence of fetal acidosis [Ephedrine]

MAC, amphetamine

Ocular – ___ [Ephedrine]

mydriasis

Metabolic – ___ [Ephedrine]

no hyperglycemia

Uterine blood flow – NOT* the “drug of choice” - higher incidence of ___ [Ephedrine]

fetal acidosis

Crosses blood ___ ___ [Ephedrine]

brain barrier

Mostly ___ by direct effect [Phenylephrine]

alpha1

alpha1>___>>>>>___ [Phenylephrine]

alpha2, beta

Acts more like ___ [Phenylephrine]

norepinephrine

Indications Increase BP due to ____ or ___. [Phenylephrine]

sympathetic blockade or peripheral vasodilation

Indications Increase BP in patients with ___ or ___ to avoid increased HR [Phenylephrine]

CAD or aortic stenosis

Indications Maintain BP during ___ ___ [Phenylephrine]

carotid endarterectomy

Indications Slow HR from ___ [Phenylephrine]

SVT

Indication ___decongestant, mydriasis [Phenylephrine]

Nasal

Indication Prolong duration of ___ anesthesia [Phenylephrine]

spinal

CV effects ___ – peripheral vasoconstriction, increase in BP; increased susceptibility to ___ [Phenylephrine]

Alpha1, dysrhythmias

CV effects Decrease in CO due to ___ or ___ [Phenylephrine]

increased afterload or reflex bradycardia

CV effects ____ blood flow to the kidneys, skin, and splanchic system [Phenylephrine]

Decreased

CV effects ___ flow to the coronary arteries [Phenylephrine]

Increased

CV effects ___cerebral oxygen saturation* [Phenylephrine]

Decreased

Selective alpha2-adrenergic agonist: (2)

Clonidine, dexmedetomidine

Centrally acting partial___ agonist [Clonidine]

alpha2-adrenergic

Antihypertensive, alpha2>___>>>>>___ [Clonidine]

alpha1, beta

Decreases sympathetic output from the ___ [Clonidine]

CNS

MOA Stimulates alpha2 inhibitory neurons in the ___ ___center [Clonidine]

medullary vasomotor

MOA Decreased ___outflow [Clonidine]

sympathetic

MOA ___ ___ hyperpolarized in the CNS [Clonidine]

Cell membranes

MOA Neuraxial – inhibits spinal ___ release and blunts perception of ___ [Clonidine]

substance P, noxious stimuli

CV effects Decreases in ___, ___, and ___ [Clonidine]

BP, HR, and CO

CV effects ___ are maintained; avoid orthostatic hypotension [Clonidine]

Reflexes

CV effects Renal blood flow is____ [Clonidine]

maintained.

Indications Analgesia – neuraxial – without ____, pruritus, nausea and vomiting, or delayed gastric emptying [Clonidine]

depression of ventilation

Premedication – ___ from laryngoscopy ___ lability of BP and HR ____catecholamine concentrations ___ MAC and requirements of injected drugs ____ effect of ephedrine [Clonidine]

Blunts response Decreases Decreases Decreases Accentuates

Premedication cont. ____ incidence of myocardial ischemic episodes in patients with CAD ___the effect of regional anesthesia (may need to give more fluid) Diagnose pheochromocytoma –____ release of catecholamines from nerve endings, not pheo Treatment of opioid withdrawal – ___of CNS Treatment of shivering –____ central thermoregulatory control, vasoconstriction – more susceptible to hypothermia [Clonidine]

Decreases, Prolongs, reduces, inhibition, inhibit

Considered sympatholytic due to ____ release of norepinephrine [Clonidine]

decreased

Agonist effect on ___ ___ – 50% reduction in anesthetic requirements MAC [Clonidine]

postsynaptic alpha2

Decreased catecholamine levels – may require___ to treat bradycardia [Clonidine]

anticholinergic

___ ___ if abruptly stopped [Clonidine]

Rebound hypertension

___ ___ agonist [Dexmedetomidine]

Alpha2-adrenergic

___X more selective for ____receptors than clonidine [Dexmedetomidine]

7, alpha2

____duration of action than clonidine (2 hr ½ life) [Dexmedetomidine]

Shorter

[Dexmedetomidine]

Sedation and analgesia with little ____ [Dexmedetomidine]

depression of ventilation

Increased likelihood of ____ and ___ [Dexmedetomidine]

hypotension and hypothermia

If used for longer than 24 hours, ____symptoms may be seen – rebound hypertension. [Dexmedetomidine]

withdrawal

Rapid injection can cause ____. – Recommended loading dose is ___mcg/kg over ___ min. Maintenance rate of___ mcg/kg/hr. [Dexmedetomidine]

hypertension, 1, 10 0.2-0.7

Selective beta2-adrenergic agonists

Albuterol

Selective ____ [Albuterol]

beta2

beta2>>___>>>>___ [Albuterol]

beta1, alpha

Indications Prevention and treatment of bronchoconstriction in___ or ___ [Albuterol]

asthma or COPD

Stop premature___ contractions [Albuterol]

uterine

Inhaled route minimizes side effects; inhaler delivers ___% of dose to lungs; an ETT decreases that amount by___% [Albuterol]

12, 50-70

Side effects Tremors – ___ receptors on skeletal muscles [Albuterol]

beta2

Increased ___, vaso___ [Albuterol]

HR, dilation

Relaxation of ____ vasoconstriction [Albuterol]

compensatory

____, ___, __ with acute administration Additive with volatile agent [Albuterol]

Hyperglycemia, hypokalemia, hypomagnesium

Additive with ___agent [Albuterol]

volatile

Alpha agonists ___ alpha1>alpha2>>>>>beta ___ alpha2>alpha1>>>>> beta

phenylephrine Clonidine

Mixed alpha and beta agonists ___ alpha1=alpha2; beta 1= beta 2 ___ alpha1=alpha2; beta 1>> beta 2

Epinephrine Norepinephrine

Beta agonists ___ beta 1= beta 2>>>>alpha ____ beta 1> beta 2>>>>alpha ___, ___ beta 2>> beta 1>>>>alpha

Isoproterenol Dobutamine Albuterol, terbutaline

Dopamine agonists ___ D1=D2>> beta >>alpha

Dopamine

Regulates ___ ___ by affecting the kidney’s handling of water [Vasopressin (arginine vasopressin) Antidiuretic hormone (ADH) ]

extracellular fluid

Principles sites of action ___ – water reabsorption V2 ___ – arterial vasoconstriction V1 [Vasopressin (arginine vasopressin) Antidiuretic hormone (ADH) ]

Kidney Vessels

20 units – diluted to ___U/cc 1 unit – approx. 20 mm systolic increase [Vasopressin (arginine vasopressin) Antidiuretic hormone (ADH) ]

1 20 mm

Refractory hypotension after ___, ___, ___ [Vasopressin (arginine vasopressin) Antidiuretic hormone (ADH) ]

ephedrine, phenylephrine, etc.

Its antidiuretic effects can lead to____ and ___. [Vasopressin (arginine vasopressin) Antidiuretic hormone (ADH) ]

water intoxication and hyponatremia.

Because of AVP's powerful ___ response, it should be administered cautiously to patients with coronary artery disease because it ___coronary arteries (thereby reducing oxygen delivery) and increases myocardial oxygen demand by increasing ___ on the heart. [Vasopressin (arginine vasopressin) Antidiuretic hormone (ADH) ]

constrictor, constricts, afterload

Produced in ___; released by ____pituitary gland [Vasopressin (arginine vasopressin) Antidiuretic hormone (ADH) ]

hypothalamus, posterior

Dose: IV bolus ___ unit IV infusion ___ units/min [Vasopressin (arginine vasopressin) Antidiuretic hormone (ADH) ]

0.5-1 0.01-0.04

First line drug for ___ or ___ vasoplegia refractory to catecholamines (___is next best drug – scavenges nitric oxide and inhibits MAO to increase NE) [Vasopressin (arginine vasopressin) Antidiuretic hormone (ADH) ]

ACEI or ARB, methylene blue

56 year old male, treated with an angiotensin II receptor antagonist for HTN, presented for placement of a cochlear implant during general anesthesia Intraop, he had profound hypotension that was resistant to decreasing anesthetic depth, fluid bolus, as well as ephedrine, phenylephrine, and epinephrine. Treated successfully with vasopressin infusion (___U/min) [Vasopressin (arginine vasopressin) Antidiuretic hormone (ADH) ]

0.06