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Vasopressors Flashcards

1
Q

Dobutamine

(mechanism of action)

A

♦ Inotrope ♦

♦ Stimulates

beta 1+++++ = ⇡ heart rate and stroke volume (inotropy/chronotropy) = increased cardiac output

beta 2+++ vasodilates arteries = decreased SVR (afterload)

alpha 1 + vasoconstriction of arteries = increased SVR (afterload)

(if heart is already working as hard as it can, the secondary effect may be dominant, causing a drop in blood pressure)

⇔used alone, effect unpredictable⇔

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2
Q

Dobutamine

(onset / duration)

A

♦ Onset 1 - 2 minutes

(may take up to 10 min for peak effect)

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3
Q

Dobutamine

(side effects)

A

Tachycardia

Ventricular Ectopy / Palpitations

Headache

Nausea/Vomiting

Hypertension/Hypotension

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4
Q

Dobutamine

(indications)

A

Cardiogenic Shock associated with Hypotension

(as an add-on or secondary med)

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5
Q

Dobutamine

(contraindications)

A

Hypersensitivity

* use with caution in pt’s with AMI, unstable angina, or severe CAD, as dobutamine can intensify or extend myocardial ischemia

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6
Q

Dobutamine

(adult dose)

A

2 - 20 mcg/kg/min IV/IO

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7
Q

Dobutamine

(pediatric dose)

A

2 - 20 mcg/kg/min IV/IO

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8
Q

Dobutamine

(pregnancy safe)

A

Class C

No adequate or well-controlled studies have been conducted in pregnant women. Use dobutamine during pregnancy only when the expected benefits clearly outweigh the potential risks to the fetus

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9
Q

Dopamine

(mechanism of action)

A

Stimulates:

beta 1 ++++ inotrophy / chronotropy = increased cardiac output

beta 2 ++ vasodilate arteries = decreased SVR (afterload)

alpha 1 +++ → vasoconstriction = increased SVR (afterload)

(stronger effect on cardiac output than it does on SVR [afterload])

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10
Q

Dopamine

(onset and duration)

A

Onset 2 - 5 mins

Duration < 10 min (after stopping infusion)

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11
Q

Dopamine

(side effects)

A

Tachydysrhythmias / Ectopy

Headache

Angina

Nausea/Vomiting

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12
Q

Dopamine

(indications)

A

Cardiogenic Shock associated with Hypotension

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13
Q

Dopamine

(contraindications)

A

♦ Hypovolemic Shock where Complete Fluid Resuscitation has NOT Occurred

♦ Uncorrected Tachydysrhythmias or V-fib

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14
Q

Dopamine

(adult dose)

A

2 - 20 mcg/kg/min IV/IO

1600 mcg/mL concentration

  • ♦ 1-5 mcg/kg/min - mainly affects renal arteries*
  • ♦ 5-20 mcg/kg/min - inotropic / chronotropic and systemic vasoconstriction*
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15
Q

Dopamine

(pediatric dose)

A

2 - 20 mcg/kg/min IV/IO

1600 mcg/mL concentration

(same as adult)

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16
Q

Dopamine

(pregnancy safe)

A

Class C

Use is recommended only if clearly needed and the benefit outweighs the risk to the fetus.

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17
Q

Epinephrine Infusion

(mechanism of action)

A

Stimulation of:

beta 1++++ ⇡ heart rate and stroke volume = increased cardiac output

beta 2+++ vasodilation of arteries = decreased SVR (afterload)

alpha1+++++ pure vasoconstriction of arteries = increase in SVR (afterload)

  • (indirectly causes coronary artery vasodilation)*
  • (dose for dose, Epi will increase cardiac output MORE than Norepi)*
  • (Epi + Dopamine will increase cardiac output BUT maintain SVR, which increases MAP)*
  • (Norepi will increase SVR AND maintain cardiac output, which increases MAP)*
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18
Q

Epinephrine

Push Dose Pressor

(onset / duration)

A

Onset < 1 min

Duration +/- 5 - 10 min

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19
Q

Epinephrine

(side effects)

A

Palpitations

Hypertension

Dysrhythmias

Anxiety

Tremors

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20
Q

Epinephrine

(indications)

A

V - Fib / Pulseless V - Tach

Asystole / PEA

Anaphylaxis

Bronchospasm

Hypotension

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21
Q

Epinephrine

(contraindications)

A

None Listed

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22
Q

Epinephrine

Anaphylactic Shock / Allergic Reaction

(adult dose)

A

♦ 0.3 – 0.5 mg 1:1,000 solution IM

♦ May be repeated every 20 minutes up to three times for a total of 4 doses

♦ If patient is hemodynamically unstable, administer 1:10,000 solution up to 0.5mg IO/IV.

Titrate to effect.

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23
Q

Epinephrine

Anaphylactic Shock / Allergic Reaction

(pediatric dose)

A

♦ 0.01 mg/kg 1:1,000 IM max 0.5 mg

→ may repeat q 20 mins for a total of 4 doses

♦ Hemodynamically Unstable → 1:10,000 0.01 mg/kg

up to 0.5 mg IV/IO titrate to effect

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24
Q

Epinephrine

(pregnancy safe)

A

Class C

Epinephrine is only recommended for use during pregnancy when benefit outweighs risk.

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25
**Norepinephrine** (Levophed) ## Footnote **(mechanism of action)**
Stimulates: **beta 1+++** ⇡ HR and stroke volume = ***increased cardiac output*** **beta 2++** vasodilation of the arteries = ***decreased SVR*** (afterload) **alpha 1+++++** vasoconstriction of the arteries = ***increased SVR*** (afterload) (**stronger effect on SVR** *_than_* on cardiac output) (increases SVR while ***maintaining*** or slightly increasing **cardiac output**) *(good broad spectrum vasoactive agent when it's unclear what is going on)*
26
**Norepinephrine** (Levophed) ## Footnote **(onset / duration)**
27
**Norepinephrine** (Levophed) ## Footnote **(side effects)**
Tissue Hypoxia Brardycardia (*increase in afterload from α-1 stimulation results in a reflex bradycardia*) Anxiety Headache Respiratory Difficulty Extravasation Necrosis
28
**Norepinephrine** (Levophed) ## Footnote **(indications)**
**\>\>Hypotension\<\<** **»Septic Shock«**
29
**Norepinephrine** (Levophed) ## Footnote **(contraindications)**
♦ Hypotension From Blood Volume Deficits ♦ Mesenteric or Peripheral Vascular Thrombosis
30
**Norepinephrine** (Levophed) ## Footnote **(*adult* dose)**
2 - 20 mcg/min IV/IO Titrate every 3 - 5 mins
31
**Norepinephrine** (Levophed) ## Footnote **(*pediatric* dose)**
0.1 - 2 mcg/kg/min Titrate every 3 - 5 mins
32
**Norepinephrine** (Levophed) ## Footnote **(pregnancy safe)**
**Category C** Use is recommended ***only if clearly needed and*** the ***benefit outweighs the risk*** (*Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans*)
33
**Phenylephrine** (Neo-Synephrine) ## Footnote **(mechanism of action)**
♦ **Pure** ***α-1 adrenergic receptor agonist*** ♦ ***Increases SVR (afterload) =** increased MAP, and **_total_ peripheral vascular resistance*** Effect on cardiac output depends on preload-responsiveness versus the ability of the heart to handle increased afterload.*(example, a patient with systolic heart failure and volume overload, added preload won't help, whereas the heart may be unable to tolerate afterload – so the net effect is to reduce the cardiac output. Alternatively, for a patient who is preload-responsive with a stronger ejection fraction, phenylephrine could cause a net increase in cardiac output.)*
34
**Phenylephrine** (Neo-Synephrine) ## Footnote **Push Dose Pressor** **(onset / duration)**
Onset **\< 1 min** Duration **+/- 10 - 20 min**
35
**Phenylephrine** (Neo-Synephrine) ## Footnote **(side effects)**
**♦ Hypertension** **♦ Bradycardia** (as mean arterial pressure increases, vagal activity also increases, resulting in reflex bradycardia) **♦ Headache** **♦ Dizziness** **♦ Dysrhythmias** **(\*\*also causes vasoconstriction of coronary arteries\*\*)**
36
**Phenylephrine** (Neo-Synephrine) ## Footnote **(indications)**
♦ Hypotension ♦ Neurogenic Shock ♦ Spinal Shock (below level of T-6) (***preferred PD pressor in presence of tachycardia***)
37
**Phenylephrine** (Neo-Synephrine) ## Footnote **(contraindications)**
\>\> **Hypovolemia** \<\<
38
**Phenylephrine** (Neo-Synephrine) ## Footnote **(*adult infusion* dose)**
**40 - 180 mcg/min** IV/IO
39
**Phenylephrine** (Neo-Synephrine) ## Footnote **(*pediatric* infusion dose)**
## Footnote **0.1 - 0.5 mcg/kg/min**
40
**Phenylephrine** (Neo-Synephrine) ## Footnote **(pregnancy safe)**
**Category C** ## Footnote Should be ***given*** to a pregnant woman ***only if the potential benefit justifies the potential risk*** to the fetus.
41
**Epinephrine** **Asystole / PEA / V-fib / V-Tach** **(*adult* dose)**
**1 mg 1:10,000** solution IO/IV **every 3 – 5 minutes** ## Footnote ***until ROSC***
42
**Epinephrine** **Bradycardia / Medical Hypotension** **(*adult* dose)**
Set drip at **0.5 – 10 mcg/min** IO/IV
43
**Epinephrine** **Push Dose** **(*adult* and pediatric dose)**
♦ Push Dose **5 - 20 mcg / 0.5 - 2 mL q 2 - 5 min**
44
**Epinephrine** **Push Dose Mixing Instructions** **(adult and pediatric)**
**Mixing** Take 10 mL syringe with 9 mL NS. Draw up 1 mL (0.1 mg) of 1:10,000 Epi from a pre-mixed vial. (concentration is 10 mcg/mL) ***_OR_*** Take 1 mL 1:1,000 Epi and mix in a 100 mL bag of NS (resulting concentration is also 10 mcg/mL 1:1,000 Epi
45
**Epinephrine** **Reactive Airway Disease** **(adult dose)**
**0.3 mg 1:1,000** solution ***_IM_***
46
**Epinephrine** **Reactive Airway Disease** **(*pediatric* dose)**
**0.1 mg/kg 1:1,000** solution ***_IM_***
47
**Phenylephrine (Neo-Synephrine)** **Push Dose** **(adult and pediatric dose)**
**50 - 200 mcg** (***0.5 - 2 mL***) **q 2 - 5 min**
48
**Phenylephrine (Neo-Synephrine)** **Push Dose** **(mixing instructions)**
Take a 3mL syringe, draw up 1 mL Phenylephrine with 10 mg/mL concentration Inject this into a 100 mL bag NS Resulting concentration is 100 mcg/mL ***_Alternatively_*** take 1 mL 1:1,000 Epi and mix into 100 mL bag NS = 10 mcg/mL Epi 1:100,000 concentration
49
**Examples of *Inotrope* Medications Include**
**Digoxin** - increased contractility **Dopamine** - increased contractility (also increases heart rate) **Dobutamine** - increased contractility (also increases heart rate) **Milrinone** - increased contractility
50
**When is Dopamine useful?**
***Hypotension likely caused by vasodilation*** due to cardiac arrest, anaphylaxis, or sepsis, or when the heart is not contracting hard enough or fast enough. ***Must give fluids FIRST*** Also used in heart block and bradycardia in order to help maintain blood pressure and increase the heart rate. ***NOT* first-line in sepsis or anaphylaxis**.
51
**Problems Associated With Dopamine**
♦ Ionotropic effects can cause ***increased oxygen demand*** / increased contractility can cause HTN ♦ Chronotropic effects can cause ***dysrhythmias*** if multiple pacemaker cells are stimulated at once ♦ Abdominal pain/nausea/vomiting come from vasoconstriction in the gastrointestinal system
52
**Cardiogenic Shock =**
**Pump Failure/Sick Heart** (low stroke volume from low ejection fraction or MI that is impairing ejection fraction)
53
**Cardiogenic Shock Effects on** **CO/SVR/CVP**
Cardiac output: **Decreased** Afterload (SVR): **Increased** Preload (CVP): **Increased** (JVD, Pulmonary edema)
54
**Cardiogenic Shock Treatment Goal**
**Increase** cardiac output *AND* **Decrease** SVR (afterload) ¤ (Be careful - decreasing SVR (afterload) in an already sick heart/hypotension may reduce pressure even further)
55
**Phenylephrine is not a good choice for cardiogenic shock because?**
Phenylephrine is alpha only (**⇡** SVR) (Afterload (SVR) is already increased, further increases in afterload (SVR) may worsen stroke volume, leading to a further reduction in cardiac output)
56
**Why would Epi not be the best first-line med choice for cardiogenic shock?**
Epi has strong beta-1 (inotropic/chronotropic) stimulation, increases cardiac output but maintains afterload (SVR) (ie. increased myocardial oxygen demand to an already stressed heart compared to norepi)
57
**Is Phenylephrine a Good Choice for Use in Cardiogenic Shock?** **Why?**
**NO** Phenylephrine is pure Alpha which causes arterial constriction. (increased afterload/SVR) *Since SVR (afterload) is already increased due to the shock state, increasing SVR (afterload) more, may worsen stroke volume, leading to a further reduction in cardiac output.*
58
**Distributive Shock Effects on** **CO/SV/SVR** **(ie. sepsis / anaphylaxis)**
**Cardiac Output:** decreased/normal, or slightly increased **Stroke Volume:** decreased, or no change **SVR** **(afterload)****:** decreased **Heart Rate:** increased *(decreased afterload and preload = decreased stroke volume and cardiac output)*
59
**Distributive Shock is Caused by?**
Inflammation making the blood vessels “leaky”, causing fluid to leak into the interstitial spaces (preload is the most sensitive to volume changes) The inflammation of the arterial system initiates histamine release causing dilation of the peripheral arteries which decreases afterload and then preload. Decreased preload ⇢ causes a decrease in stroke volume ⇢ decreased stroke volume causes an increase in HR in attempt to maintain cardiac output.
60
**What Is The First Intervention When Treating Septic Shock?**
Volume Expansion ie. Fluid Bolus 30mL/kg (the first thing affected due to hypovolemia is preload)

Medications (7 decks)

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