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INOTROPES
Critical Care Internship
Program
Dr. T. Madayag
Cholinergic transmission is
mediated by Ach
Adrenergic transmission is
mediated by
epinephrine (adrenal medulla)
norepinephrine (post ganglionic
neurons)
Ach Effects
HEART
Decreased heart rate by reduction in
SA firing
Increased conduction through the AV
node
VESSELS
Vasodilation
Receptor Physiology
Alpha 1
Alpha 2
Beta 1
Beta 2
Dopaminergic
Vasopressin (V1)
Alpha 1
Alpha 2
Beta Receptors
Beta 1
Most common in the heart
Stimulation causes
Increased rate (Chronotropic effect)
Contractility (Inotropic effect)
Increased CO & performance
Dopamine Receptors
7 sub-types
Present in renal, splanchnic, coronary
& cerebral vascular beds
D4 receptors identified in the heart
Increases CO by
Improving contractility
Heart rate
MI
Sepsis
Pulmonary embolism
Trauma
Anaphylaxis
Types of shock
Hypovolemic
Cardiogenic
Neurogenic
Obstructive
Distributive
Septic
Management of Shock
Management of adequate
systemic pressure for optimal
tissue perfusion
Maintain MAP of 60 mm Hg
Fluid resuscitation
Optimize LV function via
inotropes and vasopressors
Vasopressors
Increase SVR increase BP
Inotropes
Increases CO by contractility
Note
Drugs may influence several
receptor sites
May be dose dependent
BP may increase via direct &
indirect responses
Phenylephrine (neosynephrine)
Vasopressin
Norepinephrine (Levophed)
Epinephrine
Dopamine
Dobutamine
Increased SVR
Decreased CO
Phenylephrine (neosynephrine)
Vasopressin
Norepinephrine (Levophed)
Epinephrine
Dopamine
Dobutamine
Decreased SVR
Increased CO
Treatment of shock
Drug Overview
Phenylephrine (Neosynephrine)
Useful in neurogenic shock
Also when the SVR700 & CO not impaired
Hyperdynamic sepsis
Epinephrine
Vasopressin (ADH)
Used in
DI
Esophageal variceal bleeding
Norepinephrine (Levophed)
Dopamine (Intropin)
Precursor of epinephrine
&norepinephrine
Mediated by dopaminergic
receptors
Dose dependent
Low doses (2-5 mcg/kg/min)
D-1 receptors in renal, mesenteric,
coronary, & cerebral beds leads to
vasodilation
Use of dopamine for acute renal failure not
supported and should be eliminated
Dopamine (Intropin)
Higher Doses
Pure alpha
Vasoconstriction
Increases SVR
Dopamine (Intropin)
Adverse Effects
Tachycardia,
Tachyarrhythmia
Excessive vasoconstriction (dose
dependent)
Increased myocardial O2 demand
Dobutamine (Dobutrex)
Not a vasopressor
Inotrope that causes vasodilation
Predominant beta-1 receptor activity
inotropy & chronotropy
LV filling pressures
Net effect:
CO
Decreased SVR (with or without a small
reduction in BP)
*CO may be decreased as a result of marked
decrease in SVR (afterload)
Septic shock
Maintain MAP 65 mm Hg
Norepinephrine (Levophed) is the first line
agent when vasopressors indicated
Cardiogenic shock
In low output cardiogenic shock,
Norepinephrine (Levophed), Dopamine +/Dobutamine
Hypovolemic shock
FLUIDS
Neurogenic shock
Dopamine