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PT3: L3.2
Vasoactive Agents (Drugs)
| Question | Indication | MOA | Dose |
|---|---|---|---|
| Phenylephrine | – Used during post-op hypotension – Useful in tachydysrhythmias (lacks Beta-agonism) – Useful in Beta adrenergic receptor desensitization – Limited data supporting it use in septic shock • Potentially effective, especially in combination with dobutam | – Pure vasopressor (^ SVR) – Does not ^ CO or HR | |
| Epinephrine | Useful in septic shock, cardiogenic shock ( at lower doses) 26 p , g ) and following cardiac surgery | – Vasopressor (^ SVR) – Strong inotrope (^ CO) – Has stronger Beta receptor agonism than other mixed vasopressor / inotropic agents | Frequently used after norepinephrine > 1 mcg/kg/min |
| Dopamine | – Useful for initial empiric treatment of shock – After etiology 28 discovered change to appropriate therapy | – Vasopressor (^ SVR) – Inotrope (^ CO) – Natruretic agent (renal artery vasodilation)? | Low doses ^perfusion to kidneys? •Renal perfusion –1-3 mcg/kg/min –Dopaminergic effects ^ renal artery vasodilation •Vasopressor/inotropic effects –4-10 mcg/kg/min –^SVR&CO •Added vasopressor/inotropic effects –11-20 mcg/kg/min –Further ^SVR&CO ( |
| Dobutamine | – Useful in cardiogenic shock – After cardiac surgery patients with low CO – Also useful in sepsis | – Inotrope (^ CO) – Vasodilatory properties (v PAP v SVR) | • Doses > 5 mcg/kg/min are associated with ^ tachyarrhythmias • Doses > 20 mcg/kg/min are seldom tolerated |
| Milrinone | – Congestive heart failure – Cardiac surgery patients with v CO – Synergistically used with dobutamine to further ^ CO – Can be used in CHF with pts on beta-blockers | – Inotrope (^ CO) – Vasodilatory properties (v PAP v SVR) | Can precipitate cardiac arrythmias. Accumulates in renal failure, renal adjust for CrCl < 50 mL/min |
| Nitroglycerin | • NO activates guanylate cyclase resulting in increased intracellular concentrations of cGMP • Leads to the dephosphorylation of the light chain of myosin, resulting in vasodilation | – Strong venous dilator (v PAWP, filling pressure) – Moderate arterial dilator (v SVR) | Methemoglobinemia can occur but is rare. Bradycardia |
| Nitroprusside | Hypertensive Emergency, short term AL v in CHF • NO activates guanylate cyclase resulting in increased intracellular concentrations of cGMP • Leads to the dephosphorylation of the light chain of myosin, resulting in vasodilation | – Strong arterial dilator (v SVR) – Strong venous dilator (v PAWP, filling pressure) | Met to cyanide then thiocyanate by liver excreted by kidneys • v CL and accumulation of toxic met can occur in hepatic or renal dysfunction. Cyanide tox can occur (> 2 mcg/mL) Treatment of methemoglobinemia involves 1 mg/kg of a 1% methylene blue so |
| Nicardipine | Superiority over nitroprusside | Selective vascular smooth muscle relaxants via calcium channel blockade | |
| Nesiritide | – Treatment of acutely decompensated CHF in patients with dyspnea at rest or with minimal activity | – Recombinant human B-type natriuretic peptide (BNP) • Binds to guanylate cyclase on vascular smooth muscle and endothelial cells • Results in intracellular concentrations of cGMP | Contraindicated – Cardiogenic shock if used as primary therapy (not a direct inotrope, in CO secondary to afterload reduction) – Patients with SBP < 90 |
| Vasopressin | Increases water absorption, Vasopressor (increase SVR), does not increase CO or HR | V1a receptor agonists cause vasoconstriction | Only continuous IV. 0.01 - 0.04 units/min For sepsis, start at 0.04 units/min |
Created by:
Nami01
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