Kyle Lecture Vasopressors/inotropes

Question 1

Catecholamine synthesis

Answer 1

Tyrosine
TH
Dopa
AADC
Dopamine
DBH
Norepinephrine
PNMT
Epinephrine

Question 2

How are you going to fix bradycardia if the patient is hypertensive

Answer 2

Glycopyrrolate 0.2

Emergency-atropine

Question 3

Beta agonist MOA (WEEDS)- in cardiac myocyte

Answer 3

Binds BAR

Upregulates cAMP

Activating PKA

Causes increased calcium influx and release from SR

Question 4

Role of calcium in myocardial contractility

Answer 4

Direct interaction with cardiac troponin (actin)

Causes binding’movement of myosin head

Question 5

Beta Agonism (weeds) smooth muscle

Answer 5

cAMP and PKA block calcium influx!!

=Vasodilation via B2

Question 6

Vascular smooth muscle contraction

Answer 6

Increased calcium

Calcium binds camodulin

CaM- activates myosin light chain kinase

MLCK phosphorylates the myosin light chain

This creates a cross bridge and creates contraction

Question 7

What is present in myosin light chain contraction

Answer 7

Phosphate

Question 8

What is myosin light chain without phosphate?

Answer 8

Relaxed

Question 9

Difference between Beta agonism in the heart VS VSM

Answer 9

Heart- brings in Ca

VSM- blocks Ca

Question 10

Role of IP3 in Alpha activation

Answer 10

Calcium release from endoplasmic reticulum

Question 11

DAG

Answer 11

Alpha activation of smooth muscle

Activates protein kinase C

Which leads phosphorylation of MLCs=contraction

Question 12

Adverse effects of Epinephrine

Answer 12

Hyperglycemia
Hypokalemia
Lactic acidosis
Myocardial ischemia

Question 13

Epi Dosing

Answer 13

Moderate hypotension-5-10 mcg

Infusion 0.02-0.3 mcg/kg/min

Low dose epi if<0.05 vasodilation due to B2
Higher doses see predominately alpha 1

Question 14

What will you see with low dose Epi

Answer 14

Beta 2 vasodilation

See alpha vasoconstriction at higher doses

Question 15

Impact of norepinephrine on CO and HR

Answer 15

NOTHING

CO may decrease

Question 16

Dopamine Dosing

Answer 16

Low dose 0.5-3 mcg/kg/min RENAL

Moderate 3-10 mcg/kg/min Beta 1

High 10-20 mcg/kg/min Alpha 1

Question 17

List 3 inodilators

Answer 17

Dobutamine

Isoproterenol

Milrinone

Question 18

When will you see Isoproterenol and what are 2 adverse effects

Answer 18

Stress echo- PUUUUUre Beta stimulation

Tachycardia/palpitations
Flushing

Question 19

What impact does milrinone have on adrenergic receptors?

Answer 19

Trick question, fuck you its a PDE3 inhibitor that increases cAMP and therefore Ca in the myocardium

Question 20

Dosing phenylephrine

Answer 20

5-200 mcg
0.2-2 mcg/kg/min

Question 21

Hypotension in setting of spinal in C-section?

Answer 21

Phenylepherine

Previous recommendation was ephedrine

Question 22

Considerations and effects for phenylephrine

Answer 22

Do you have a heart rate? You really need a heart rate Jack

Severe Reflex bradycardia with pure alpha stimulation

Question 23

What’s your indirect/direct agent?

Answer 23

Ephedrine 5-10 mg

Question 24

Dosing Vasopressin

Answer 24

Low and slow

0.5-2 units… probs just 0.5 units

Reflex bradycardia

Question 25

Electrolyte abnormalities you will see increased digoxin toxicity

Answer 25

Hypokalemia Hypomagnesemia Hypercalcemia

Question 26

RAAS

Answer 26

Renin release Conversion of angiotensinogen to angiotensin I in Liver Conversion Via ACE to angiotensin II which is our vasoactive molecule

Question 27

Angiotensin receptor stimulation

Answer 27

Vasoconstriction Salt retention Vascular growth

Question 28

Which is the only cardiac med we have people hold before surgery?

Answer 28

ACE-I ARAs

Question 29

What do you give in setting of refractory hypotension in patients on an ace inhibitor?

Answer 29

Vasopressin

Question 30

Impact of nitroglycerin on vasculature

Answer 30

VENO dilation Liver decongestant Do not give in PRELOAD dependent states (right sided MI)

Question 31

What do Beta blockers depress?

Answer 31

Central vasomotor center in the brain Heart Renin release from the kidney

Question 32

What patient population are we cautious with beta blockers?

Answer 32

Asthmatics B2 inactivation causes bronchoconstriction

Question 33

Which beta blocker causes the release of nitric oxide

Answer 33

Nebivolol

Question 34

Which beta blocker has alpha antagonism effects?

Answer 34

LAbetolol

Question 35

Selective Beta blockers

Answer 35

Metoprolol Esmolol Atenolol Nebivolol Biosprolol

Question 36

Nonselective beta blockers

Answer 36

Labetolol Carvedilol Propranolol Nadolol Sotalol

Question 37

What do you give with HTN and a high heart rate?

Answer 37

Metoprolol

Question 38

What do you give with hypertension and a normal heart rate?

Answer 38

Labetolol

Question 39

What do you give with normotensive patient with high heart rate?

Answer 39

A beer Esmolol

Question 40

CCB with most cardiac effects

Answer 40

Verapamil

Question 41

Best drug to give to lower SVR in patient with LV systolic dysfunction and an EF<30

Answer 41

Amlodipine

Question 42

Metabolism of clevidipine

Answer 42

Nonspecific esterases

Question 43

Selective alpha blockers

Answer 43

Prazosin Indoramin Terazosin Doxazosin

Question 44

Nonselective alpha blockers

Answer 44

Phentolamine Phenoxybenzamine

Question 45

Difference between phenoxybenzamine and phentolamine

Answer 45

Phenoxybenzamine is a non competitive antagonist- long duration of action

Question 46

Only time you will maybe give an alpha blocker

Answer 46

Pheocryocytoma? Hyperplasia of adrenal medulla and exaggerated sympathetic response

Question 47

What to give in low heart rate high BP

Answer 47

Hydralazine

Question 48

What’s your only venodilator

Answer 48

Nitroglycerin

Question 49

What drug acts on venous an arteriolar

Answer 49

Nitroprusside

Question 50

What is the defining factor of hypertensive emergency?

Answer 50

End organ damage

Question 51

Overall… according to Kyle… what does alpha 2 agonism do?

Answer 51

Vasodilation Despite some postsynaptic alpha2B mediated vasoconstriction in the periphery

Question 52

Isosorbide metabolism

Answer 52

Hepatic, 5-6 hours Longer angina relief than. Nitro

Question 53

Digoxin toxicity

Answer 53

2-3rd degree block Bradycardia Ventricular arrhythmias N/V Visual changes

Question 54

Electrolyte imbalances that increase digoxin toxicity

Answer 54

Hypokalemia Hypercalcemia

Question 55

Drugs that increase Digoxin levels

Answer 55

Amiodarone Verapamil Quinidine Macrolide antibiotics