Therapeutics - Shock 2
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What receptors and physiologic effects does NE have?
- Receptors: B1 B2 and A1
- Physiologic effects: increases CO and BP
What receptors and physiologic effects does DA have?
- Receptors: B1 DA and A1
- Physiologic effects: increases CO, BP and HR and RBF
What receptors and physiologic effects does Phhenylephrine have?
- Receptors: A1
- Physiologic effects: increases BP, decrease HR and +/- CO
EPI (adrenalin) is used for what?
Uses: anaphylaxis, anaphylactoid reactions or cardiac arrest (pulseless VT or VF, asystole, PEA), refractory shock (EPI infusion), especiallu w/ norepinephrine failure
What drug can increase BP in patients unresponsive to other agents?
EPI is considered a second or first line agent?
What is a normal dose of EPI?
- Infusion at 1-10 mcg/min (max 30 mcg/min)
- or 0.01 to 0.1 mcg/kg/min
What are the precautions for EPI (adrenalin) use?
- Raising blood pressure may cause myocardial ischemia
- Higher doses may be required to treat poison/drug induced shock
- Incompatible with alkaline solutions (NaHCO3)
- Side effects: tachyarrhythmias, ischemia, hyperglycemia, lactic acidosis, extravasation
Norepinephrine (Levophed) is primarily an ____ agonist
What is the MOA of Norepinephrine (Levophed)?
Increases MAP by vasoconstriction
What drug is considered FIRST-LINE THERAPY for maintenance of blood pressure and tissue perfusion in septic shock?
What is the dose for Norepinephrine (Levophed)?
0.1 to 2.0 mcg/kg/min (2-30 mcg/min)
What are the Side effects of Norepinephrine (Levophed)?
Increased myocardial oxygen demand, ischemia/dysrrhythmias (alpha effects), peripheral hypoperfusion (potent vasoconstriction), tissue necrosis
What are the Drug interactions of Norepinephrine (Levophed)?
TCAs, leads to prolonged hypotension
Morality is lower when what drug is used for cardiogenic shock?
What drug is a pure alpha agonist?
What is Phenylephrine (Neo-Synephrine)useful for treating?
- Shock due to peripheral vasodilation
- Effective in patients with hypotension and tachydysrhythmias where avoidance of myocardial stimulation is desirable
Is Phenylephrine (Neo-Synephrine) a first or second line agent?
Regarded as a second line agent
What is the dose of Phenylephrine (Neo-Synephrine)?
0.5-10 mcg/kg/min (30-300 mcg/min)
What are the Side effects of Phenylephrine (Neo-Synephrine)?
Reflex bradycardia, hypertension, headache, dysrhythmia, mesenteric ischemia (potent alpha effects)
Dopamine (Intropin) is an Immediate precursor of both _________________ and ___________________.
Norepinephrine and epinephrine
What drug has variable effects depending upon dose administered?
What is Dopamine (Intropin) used for?
Used for hypotension due to sepsis or cardiac failure
When should Dopamine (Intropin) not be used?
Should not be used for renal protection
How does Dopamine (Intropin) improve splanchnic/mesenteric flow?
Mainly by increasing cardiac output
What is the dose of Dopamine (Intropin)?
Start at 2.5-5 mcg/kg/min in cardiogenic shock (range 2.5-20 mcg/kg/min)
What are the Side effects of Dopamine (Intropin)?
Tachycardia, tachydysrhythmias, extravasation, contains sulfites
What are the drug-drug interactions of Dopamine (Intropin)?
MAOIs, α and ß-blockers, phenytoin
What actions does low dose dopamine have?
- Worsens splanchnic oxygenation via redistribution
- Impair GI function
- Impair endocrine and immune systems
- Blunt hypoxemic respiratory drive
Vasopressin is AKA:
Antidiuretic hormone or ADH
What endogenous molecule is at inappropriately low levels in patients with shock?
What effect does Vasopressin have?
- Exogenous administration can restore vascular tone
- Acts on V1 and V2 receptors
- V1”vasopressin” receptors: Direct vasoconstriction of systemic vasculature
- V2 “ADH” receptors: Osmoregulation and maintenance of normovolemia
- Vasopressin enhances the sensitivity of the vascular system to other pressor agents
What is the Second line agent for refractory vasodilatory shock?
What is the dose of Vasopressin?
- 0.01-0.04 U/min added to catecholamines (like NE) can raise blood pressure in patients with pressor-refractory septic shock
- Not titrated like traditional vasopressors
- Prone to dosing errors – Units/minute
- Dose is 40 U for cardiac arrest
What are the Side effects of Vasopressin?
Arrhythmias, myocardial/gut/digit/skin ischemia, increased bilirubin
Dobutamine (Dobutrex) has what MOA?
- Positive inotropic, chronotropic, lusitropic effects
- Improves oxygen delivery, may improve mesenteric flow
What is the agent of choice for low-output states with elevated cardiac filling pressures (ADHF, cardiogenic shock)?
What is the dose for Dobutamine (Dobutrex)?
Begin at 2.5-5 mcg/kg/min, titrate to 20 mcg/kg/min
When does Dobutamine (Dobutrex) its peak effect?
Peak effect within 10 minutes
What are the Side effects of Dobutamine (Dobutrex)?
Ventricular arrhythmias, tachycardia, hypokalemia, myocardial ischemia, tachyphylaxis
What are the Drug interactions of Dobutamine (Dobutrex)?
ß-blocking agents, incompatible with alkaline solutions
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