Vasopressors: Difference between revisions
Line 46: Line 46:


==[[Milrinone]]==
==[[Milrinone]]==
===Indication===
low cardiac output states due to impaired myocardial contractility
===Primary Receptor===
*PDE-3 inhibitor
===Relative Effects===
*↑HR
*↑↑↑SV
*↓SVR
===Dosing===
*Normal renal function:
0.25 - 0.75 mcg/kg/min
*Creatinine clearance < 50mL/min, reduce infusion rate
===Rate of Titration===
*Q2H; slower titration rate if renal insufficiency
===Adverse Effects===
*Tachyarrhythmias
*Hypotension
*Myocardial ischemia
===Notes===
*Can use as alternative to dobutamine in pts with cardiogenic shock and on b-blockers
*Causes pulmonary vasodilation, may be good choice in pts with RV failure
*↑cAMP in cardiac myocytes and vascular smooth muscle, thereby ↑HR and ↑SV while decreasing ↓SVR
*Use with caution in pt with renal failure and hypovolemia


==Push Dose Pressors==
==Push Dose Pressors==

Revision as of 14:30, 20 December 2014

Background

The goal of vasopressor use is to reach critical organ perfusion pressure. Estimated required mean arterial pressures (MAP) are listed below. It is generally safe to aim for a goal map of 65 mmHg. Vasopressors also promote increased venous return.

  • Brain: MAP of 50 mmHg [1]
  • Heart: MAP of 65 mmHg[2]
  • Kidneys: MAP 65-75 mmHg[3]

IV Vasopressor have not been shown to be unsafe when used peripherally[4] If running peripherally perform frequent site check via institutional protocol. [5]

Norepinephrine

Dopamine

Dobutamine

Phenylephrine

Vasopressin

Epinephrine

Indication

  • Anaphylaxis

Primary Receptor

  • β1
  • α1
  • β2

Relative Effects

  • ↑↑↑HR
  • ↑↑↑SV
  • ↑↑↑SVR
  • Bronchodilation (β2)

Dosing

  • Dose-dependent effects:
  • 1-10 mcg/min - increase HR and SV
  • 10-20 mcg/min - increase SVR

Rate of Titration

  • Q2-5 min

Adverse Effects

  • Tachyarrhythmias
  • Myocardial ischemia
  • ↑Serum lactate
  • Splanchnic ischemia

Notes

  • ↑lactate occurs primarily from ↑glycolysis/glycogenolysis within skeletal muscles not tissue hypoperfusion
  • Use with caution in pts with CAD
    • However clinical trials have not demonstrated worsened outcomes

Milrinone

Push Dose Pressors

  • Use when need temporary BP or CO boost
    • Post-intubation hypotension
    • Propofol-induced hypotension
    • A-fib w/ hypotension
      • Easier to convert well-perfused heart

Epinephrine

  • Mix 9mL of NS with 1mL of 1:10,000 epi
    • Now have 10mL of 10mcg/mL
      • Use 0.5-2mL q2-5min (similar to epi drip)
      • Same as 2% lido with epi
        • Ok to give peripherally
  • Onset - 1min
  • Duration - 5-10min

Phenylephrine

  • Pure alpha (no effect on heart)
  • Place 1mL of 10mg/mL vial in 100mL NS
    • Now have 100mcg/mL
    • Draw up 10mL
    • Use 0.5-2mL q2-5min (50-200mcg)
  • Onset - 1min
  • Duration - 20min

Source

  1. ↑ Plöchl, W, D J Cook, T A Orszulak, and R C Daly. 1998. Critical cerebral perfusion pressure during tepid heart operations in dogs. The Annals of thoracic surgery, no. 1. http://www.ncbi.nlm.nih.gov/pubmed/9692450
  2. ↑ Emcrit Vasopressor basics http://emcrit.org/podcasts/vasopressor-basics/
  3. ↑ Bellomo, Rinaldo, Li Wan, and Clive May. 2008. Vasoactive drugs and acute kidney injury. Critical care medicine, no. 4 Suppl. doi:10.1097/CCM.0b013e318169167f. http://www.ncbi.nlm.nih.gov/pubmed/18382191.
  4. ↑ Ricard JD. et al. Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Crit Care Med. 2013 Sep;41(9):2108-15
  5. ↑ Chen J. et al. Extravasation injury associated with low-dose dopamine.. Ann Pharmacother. 1998 May;32(5):545-8
  • EmCrit Podcast 6
Retrieved from "https://www.wikem.org/w/index.php?title=Vasopressors&oldid=27399"