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Pharmacology > Cardiac - Inotropes & Pressors > Flashcards

Cardiac - Inotropes & Pressors Flashcards

1
Q

Adrenoreceptors and functions

A

(From LITFL)
A1 present in smooth muscle.
Causes vasoconstriction, relaxation of GI, contraction of GU

A2 present in CNS, arterioles, pancreas. Causes sedation, analgesia, vasodilation and inhibition of insulin release

B1 present in cardiac muscle and juxtaglomerular apparatus (JGA)
Causes ino/chrono/dromotropy (cAMP increases intracellular Ca2+) and in the JGA increases renin release.

B2 present in skeletal vascular and bronchial smooth muscle, liver and on cell membranes.
Causes vasodilation and bronchodilation, hepatic glycogenolysis, increases na+/k+ ATPase pump to increase intracellular K+

B3 present in fat, causes lipolyses and thermogenesis

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2
Q

MOA Epinephrine

A

B1- increased chrono/dromo/inotropy
B2- bronchodilation

Low doses B1&2>a1 decreased SVR
Higher doses A1>B1&2 increased SVR

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3
Q

Epinephrine dosages (adult)

A

Bradycardia/shock 2-20mcg/min
- UTD 1-40mcg

Anaphylaxis/bronchospasm 0.5mg IM, 50-100mcg IV/IO

Periarrest 10mcg IV/IO q2-3min
Intraarrest 1mg q3-5min

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4
Q

Epinephrine Formulary

A

CCP: 1mg/250mL= 4mcg/mL
OR
VCH: 3mg/250mL= 12mcg/mL
5mg/250mL= 20 mcg/mL
30mg/500mL= 60mcg/mL

Compatible with D5W, NS, LR, Ringer’s

Administer through central line or PIV for short-term

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5
Q

Pharmacokinetics of epinephrine

A

Onset: 30-90sec IM, 30sec IV
Peak: 4-10min IM, 3-5min IV
Duration: 5-10min

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6
Q

MOA of norepinephrine

A

“balanced inopressor”
A1: arteroconstriction (afterload/SVR), venoconstriction (SV/CO), and coronary artery constriction
A1>B1 and B2 effects
B1 increased contractility (and HR, but cancelled out by baroreflex-induced bradycardia)
B2 smooth vaso

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7
Q

Norepinephrine dosages (adult)

A

2-20mcg/min
*around 15mcg/min, consider layering in Vasopressin or other pressor
0.1mcg/kg/min up to 1mcg/kg/min

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8
Q

Norepinephrine indications

A
  • Shock with hypotension refractory to fluid resuscitation (*vasodilatory)
  • Cardiogenic shock with refractory hypotension
  • Symptomatic bradycardia (? handbook)
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9
Q

Norepinephrine pharmacokinetics

A

Onset and peak immediate
Duration 1-2min

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10
Q

Norepinephrine infusions

A

4mg/250mL =16mcg/mL (single strength)
8mg/250mL = 32mcg/mL (double strength)
16mg/250mL= 64mcg/mL (quad strength)
central line access is preferred, can use peripheral IV for single strength through large bore

Compatible with NS, D5W, NS-D5W

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11
Q

Dobutamine MOA

A

Inodilator

(From AHA)
3:1 B1 to B2 affinity. Potent inotrope, with weaker chronotropy. Both A1 agonism and antagonism, with B2 stimulation, cause net effect of mild vasodilation. Higher doses cause vasoconstriction

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12
Q

Dobutamine indications

A
  • Low cardiac index and low BP, but without hypotension (decompensated HF, cardiogenic shock, sepsis-induced myocardial dysfunction)
  • Short-term management of patients with cardiogenic decompensation
    MANY DRUG INTERACTIONS
    Concomitant use with MAO inhibitors May cause prolonged HTN
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13
Q

Dobutamine dosages

A

2-20mcg/kg/min (max)

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14
Q

Dobutamine infusions

A

250mg/250mL= 1mg/mL (May appear pink due to oxidation, does not effect potency)

Compatible with N/S, D5W, NS-Dex combos, Ringer’s

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15
Q

Dobutamine pharmacokinetics

A

Onset: 1-10min
Peak: 10-20mins
Half-life: 2min

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16
Q

Dopamine MOA

A

Dose dependent:
Low: D1/D2 causes decreased SVR
Medium: additionally stimulates B1 (chrono and inotropy)
High: B1 and A1 increased SVR

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17
Q

Dopamine indications

A
  • Symptomatic hypotension in the absence of hypovolemia (exp. Cardiogenic shock, bradycardia, sepsis, renal failure)
  • post-arrest hypotension
  • absence of more suitable agents
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18
Q

Dopamine pharmacokinetics

A

Onset 2-5min
Peak unknown
Duration <10min

19
Q

Dopamine dosage (adult)

A

Low (dopaminergic) 2mcg/kg/min
Medium (b1) 5-10mcg/kg/min
High (a1 and b1) 10-20mcg/kg/min

Titrate by 2-5mcg/kg/min q 2-5min to effect

20
Q

Dopamine infusion

A

400mg/250mL= 1600mcg/mL
800mg/250mL= 3200mcg/mL

21
Q

Dopamine contraindications

A

Known/suspected pheochromocytoma
Tachydysrhythmia
Extreme caution with concurrent MAO inhibitors— may cause prolonged HTN

22
Q

Norepinephrine contraindications

A

Mesenteric or peripheral vascular thrombosis, pregnancy, profound hypoxia or hypercarbia (may produce VT/VF)

23
Q

Milrinone MOA

A

Inodilator, PDE inhibitor

Inhibits phosphoduesterase 3 from breaking down cAMP, causing inotropy in cardiac and vasodilation in vascular tissue

24
Q

Milrinone indications

A

ADHF, inotropic support, cerebral vasospasm

25
Q

Contraindications/cautions of Milrinone

A

Hypersensitivity, avoid use in severe obstructive aortic or pulmonic valvular disease. Caution with renal dysfunction.
Arrhythmias associated with use, correct electrolytes (especially hypoK and hypomag) before use.

26
Q

Milrinone dosage

A

Short term management of CHF
- loading dose (optional) 50mcg/kg/10min
- maintenance 0.125 to 0.75 mcg/kg/min

27
Q

Milrinone infusion

A

20mg/100mL= 200mcg/mL
40mg/100mL= 400mcg/mL

Compatible with N/S, D5W, NS 0.45%

28
Q

Milrinone

A

Onset 5-15min
Half-life 2.3hrs

29
Q

Isoproterenol MOA

A

Inodilator
B1 ino/chronotropy
B2 relaxation of bronchial, GI and uterine smooth muscle, vasodilation of peripheral vasculature

Little/no alpha affinity

30
Q

Isoproterenol indications

A

Symptomatic bradycardia, AV blocks
Adjunct to fluid and electrolyte replacement therapy and other drugs/procedures in the treatment of low cardiac output states (ie. decompensated HF, cardiogenic shock)

31
Q

Isoproterenol contraindications

A

Hypersensitivity to Isoproterenol and sulfites.
Tachyarrhythmias
Ventricular arrhythmias on inotropic support
Digitalis toxicity
MANY drug interactions and cautions with co-morbidities

32
Q

Isoproterenol dosage

A

(handbook)
Bradycardia 2-10mcg/min
Heart block 2-20mcg/min

33
Q

Isoproterenol infusions

A

1mg/250mL= 4mcg/mL
4mg/250mL= 16mcg/mL
Compatible with D5W, NS, dextrose 5% in Lactated Ringer’s, dextrose 5% in sodium chloride 0.9%, Lactated Ringer’s solution

34
Q

Isoproterenol pharmacokinetics

A

Onset immediate
Duration 10-15min

35
Q

Vasopressin MOA

A

ADH analogue, pure vasopressor
(Uptodate)
V1 constriction of vascular smooth muscle (increased SVR), baroreflex may cause decrease in HR
V2 increases water permeability at renal tubules- decreased urine volume and increased osmolality.

Pressor effects relatively preserved during hypoxic and acidotic conditions

36
Q

Vasopressin indications

A

Vasodilatory shock states that remain hypotensive despite fluid resuscitation and catecholamines

37
Q

Vasopressin dosages

A

0.03-0.04U/min
Titrate up by 0.005U/min q10-15 to a max of 0.1U/min

38
Q

Vasopressin infusion

A

20U/100mL= 0.2U/mL
40U/100mL= 0.4U/mL
Compatible with NS and D5W

39
Q

Vasopressin pharmacokinetics

A

Onset 30-60min
Duration: 20min

40
Q

Phenylephrine MOA

A

Pure vasopressor
A1 increased SVR
May cause baroreflex reduction in HR

41
Q

Phenylephrine indications

A

Acute hypotension despite adequate fluid volume replacement in airway management (ie. vasodilation in anesthesia, post-intubation hypotension)

Consider in aortic stenosis (increased SVR, reflex brady for filling time)

42
Q

Phenylephrine contraindications/cautions

A

Hypersensitivity to phenyl or sulfites
Pheochromocytoma
Severe HTN or VT (also induced with rapid push)
Caution in bradycardia or underlying cardiovascular disease

43
Q

Phenylephrine dosage

A

100mcg/20-30sec q 2-5min

Pharmacology (6 decks)

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