INOTROPES
Background:
The word inotrope is commonly used as a blanket term for cardiovascular (CV)
active drugs that have inotropic, pressor, chronotropic, lusotropic actions:
Pressor increases systemic vascular resistance and increases blood pressure (BP)
Chronotrope increases heart rate (HR)
Lusotrope improves relaxation during diastole and decreases end-diastolic
pressure in the ventricles.
Inotrope improves myocardial contractility and enhances stroke volume.
Generally used to describe positive effect
Positively inotropic agents strength of muscular contraction.
Negatively inotropic agents weaken the force of muscular contractions.
Both positive and negative inotropes are used in the management of various
cardiovascular conditions.
The choice of agent depends largely on specific pharmacological effects of
individual agents with respect to the condition.
Positive inotropic agents
Myocardial contractility
Used to support cardiac function in conditions such as:
a) Decompensated CHF,
b) Cardiogenic shock,
c) Septic shock,
d) Myocardial infarction,
e) Cardiomyopathy, etc.
Positive inotropic agents commonly used in AICU include:
Dopamine
Dobutamine
Epinephrine (adrenaline)
Isoprenaline (isoproterenol)
Norepinephrine (noradrenaline)
Principles Of Use Of Vasopressors and Inotropes
Hypotension may result from:
Hypovolemia
Pump failure
Pathologic maldistribution of blood flow
Vasopressors are indicated for:
Decrease of >30 mmHg/20% from baseline SBP or
MAP <60 mmHg and
Evidence of end-organ dysfunction due to hypoperfusion
Hypovolemia must be corrected first
Many of the drugs act by stimulating alpha and Beta receptors in target organs.
A-receptor stimulation causes vasoconstriction
B1-receptor stimulation causes positive chronotropic and inotropic effects on the
heart
B2-receptor stimulation causes bronchodilation and vasodilation (n.b these are
the main effects)
Norepinephrine (Noradrenaline)
Direct stimulation in Alpha1 receptor: induces intense vasoconstriction of
arterial & venous vessels
Acts on Beta1 receptor (in the heart) causes: Myocardial contractility , along
with peripheral vasoconstriction contributes to arterial BP
USES: Sepsis, cardiogenic and undifferentiated shock
Usually used than Dopamine because it has less tachyarrythmias
in non-septic patient: it produces vasoconstriction in all vascular beds,
including the renal circulation
in septic patients: increases BP and SVR(systemic vascular resistance, often
without altering cardiac output.
However in some patients may increase CO by increasing stroke volume.
Often improves renal blood flow and urine output in these patients by
increasing perfusion pressure without compromising cardiac output.
It has no effect on renal blood flow in patients with established acute renal
failure
Dosing & Packing:
Ampules contain 4mg/4ml
Continuous infusion @ 2-20g/kg/min
Extravasation of norepinephrine at the site of IV administration can
cause tissue necrosis
Epinephrine (Adrenaline)
T/t for anaphylaxis & ventricular fibrillation
Direct stimulation of - receptors of the myocardium cause BP, CO &
myocardial O demand by contractility & HR
SBP rises, although - mediated vasodilation in skeletal muscle may DP
- stimulation also relaxes bronchial smooth muscle
Low Dose (<0.05-0.1 mcg/kg/min)
cardiac output -- HR
in effective circulating volume and venous return.
Net result: systolic BP rises but diastolic falls
High Dose (> 0.1 g/kg/min)
-rise in SVR (systemic vascular resistance)
decreased cardiac output
rise in both systolic and diastolic BP
Dosing & Packing:
Epinephrine is available in vials & prefilled syringes containing:
a) 1:1000 (1mg/ml)
b) 1:10,000 (0.1mg/ml [100g/ml])
Emergency situation (eg, cardiac arrest & shock), iv bolus 0.05-1 mg,
depending on the severity of cardiovascular compromise
Major anaphylactic reactions .01-.05mg (repeated, if necessary) followed by
infusion
To improve myocardial contractility or HR, a continuous infusion is prepared.
Dopamine
USES: Cardiogenic shock, second line for septic shock to improve CO, BP, &
maintain renal function
Its effect has more prominent in the heart at lower dose, and vasoconstriction
effect for higher dose.
Chronotropic & proarrhythmic effects of DA limit its usefulness in some
patients.
1) Low dose: 0.5-3g/kg/min
Activates dopaminergic receptors(specifically DA) receptors in the renal
mesenteric, cerebral, and coronary beds, resulting in selective vasodilation.
Vasodilation of renal vasculature and promotes diuresis and natriuresis
(increases renal blood flow)
Renal-dose Dopamine
Currently, there is no data to support the routine use of low dose dopamine to
prevent or treat acute renal failure or mesenteric ischemia.
2) Moderate dose: 3-10 g/kg/min
- stimulation myocardial contractility, HR, SBP, and CO -- Can
result in dose-limiting dysrhythmias
Myocardial O demand typiaclly more than supply
3) High dose: 10-20 g/kg/min
dopamine stimulates alpha receptors and produces arterial vasoconstriction
with an increased SVR (increased BP)
Caution: Arrythmogenic
Dosing & Packing:
Continuous infusion 1-20 g/kg/min
Most commonly supplied in 200mg/5 ml ampule of Dopamine
Dobutamine
Uses: in severe Heart Failure and cardiogenic shock.
in low CO states and CHF e.g. myocarditis, cardiomyopathy, MI
Primary cardiovascular effect - Cardiac ouput as a result of myocardial
contractility
PVR caused due to - activation usually prevents much of arterial BP
LV filling pressure, whereas coronary blood flow(CBF) .
In combination with Epinephrine/Norepinephrine in profound shock states to
improve CO and provide some peripheral vasodilatation
Does not selectively vasodilate the renal vascular bed.
Dosing & Packing:
Infusion @ 2-20 g/kg/min
Supplied in 250 mg/5ml ampule
stable for 24 hrs after reconstitution. May turn slightly pink during this time
but this is not associated with a change in potency
Onset of action within 2 min and maximal effect associated with a given
infusion rate occurs approximately 10 min after starting the infusion
Ephedrine
ICU INDICATIONS:
1. Drug-induced hypotension
2. Bronchospasm
haemodynamic effects are similar to epinephrine but it has a longer duration
of action and is active when administered orally.
increased cardiac contractility and heart rate and thus cardiac output
Note: used commonly in Anaesthesia but of limited utility in the ICU setting
IV:
Ampoules contain 30mg in 1ml
Dilute 30mg to a total of 10ml using normal saline (giving a concentration of
3mg/ml)
Nursing Responsibilities
The effect of these drugs vary greatly so close observation is essential
1. Nurses need to be familiar with and ensure that the correct equipment ins
working order is used.
Adequate supplies of the drug need to be accessible and prepared in good
time.
2.) Check doctors order for dose.
Parameters are set for drug delivery and therapeutic goals by medical staff
and documented on individual Care Plans
3. Drug calculations are complex and nurses must be familiar with and
understand calculations required to work out the doses. (Small errors in
dosage can have serious adverse effects)
4. All infusions must be checked at nurse/shift handover. Both syringe and
administration set must be clearly labeled. (Reduces risk of accidental rate
change and disconnection.)
5. Dedicate a lumen of the central line for inotrope use only. Never
administer non-inotropic drugs or bolus via this lumen.
(Avoids bolus administration by adding other non-inotropic drugs; ensures
that the concentration of the drug is adequately diluted. Peripheral access or
intra-osseous needle may be used until central access is available.)
6. Continuously monitor heart rate, rhythm and blood pressure and record
hourly.
Continuous monitoring of ECG
Blood pressure via an arterial line providing a continuous recording
(Tachyarrythmias, ST (ischaemic) changes and/or too high/low BP may
necessitate rate change or additional/alternate therapy.)
7. Titrate the inotrope within the prescribed limit or as instructed by doctor to
maintain the desired blood pressure, taking into account the action of the
drug and all physiological parameters.
(Ensures administration of the drug is within therapeutic boundaries.)
8. Any changes in vital signs and subsequent drug delivery are clearly
documented so that the response or effect of the drug can be assessed
easily.
DOCUMENT.
