Inotropic medications are drugs that affect the strength or force of the heart's contractions.

They are commonly used in critical care, especially for patients with heart failure, cardiogenic
shock, or after cardiac surgery, to support cardiac output.

Types of Inotropic Medications:

1. Positive Inotropes (increase contractility):

o Dobutamine: Stimulates β1-receptors to increase heart contractility; used in heart
failure and after cardiac surgery.
o Dopamine: Dose-dependent effects; low doses improve renal perfusion, moderate
doses enhance contractility.
o Epinephrine (Adrenaline): Potent inotrope and vasoconstrictor; used in shock
and cardiac arrest.
o Norepinephrine (Noradrenaline): Primarily a vasopressor with some inotropic
effects; used in septic or cardiogenic shock.
o Milrinone: A phosphodiesterase-3 inhibitor that increases contractility and causes
vasodilation; used in heart failure.
o Isoproterenol: A β-agonist used rarely for bradycardia and heart block.
2. Negative Inotropes (decrease contractility):
o Beta-blockers (e.g., metoprolol, propranolol): Reduce heart rate and
contractility; used in chronic heart failure and hypertension.
o Calcium channel blockers (e.g., verapamil, diltiazem): Decrease cardiac
workload; used in arrhythmias and hypertension.

Clinical Uses of Positive Inotropes:

 Acute decompensated heart failure

 Cardiogenic shock
 Post-cardiac surgery support
 Severe sepsis or septic shock (as adjunct therapy)
 Low cardiac output syndrome

Important Considerations:

 Positive inotropes can improve hemodynamics but may increase myocardial oxygen
demand and the risk of arrhythmias.
 Long-term use is generally avoided due to adverse outcomes unless for palliative
support or advanced heart failure with no other options.
 Dosage and selection depend on clinical context, blood pressure, heart rate, and
underlying pathology.

What Are Inotropic Medications?

Inotropes are medications that modify the force of the heart's contraction:
  Positive inotropes: Strengthen cardiac muscle contraction.
 Negative inotropes: Weaken cardiac muscle contraction (less commonly referred to in
critical care but used in long-term management of conditions like hypertension or
arrhythmias).

🔹 Positive Inotropic Agents – Detailed Overview

Drug Mechanism of Action Clinical Uses Adverse Effects

β1-adrenergic agonist → ↑ - Acute heart failure - Arrhythmias

Dobutamine myocardial contractility and stroke - Cardiogenic shock - Tachycardia
volume - Post-op support - Hypotension

Dose-dependent:
- Hypotension with - Tachyarrhythmias
Low: renal perfusion
Dopamine bradycardia - Ischemia
Moderate: β1 (↑ contractility)
- Shock with low CO - Nausea
High: α1 (vasoconstriction)

- Cardiac arrest - Hypertension

β1, β2, α agonist: ↑ contractility,
Epinephrine - Anaphylaxis - Tachycardia
HR, and vasoconstriction
- Cardiogenic shock - Lactic acidosis

- First-line for septic

- Peripheral
α1 agonist (vasoconstriction), shock
Norepinephrine ischemia
some β1 effect - Cardiogenic shock (if
- Arrhythmias
hypotensive)

- Acute
- Hypotension
PDE3 inhibitor → ↑ cAMP → ↑ decompensated heart
- Arrhythmias
Milrinone calcium → ↑ contractility & failure
-
vasodilation - Post-op cardiac
Thrombocytopenia
support

- Heart block
Non-selective β agonist (↑ HR and - Tachycardia
Isoproterenol - Bradycardia resistant
contractility, vasodilation via β2) - Hypotension
to atropine

Sensitizes troponin C to calcium - Advanced heart - Hypotension

Levosimendan (not
(↑ contractility without ↑ O2 failure - Headache
available in all countries)
demand) - Post-cardiac surgery - Arrhythmias

🔹 Negative Inotropic Agents

Used to reduce cardiac workload, particularly in conditions like hypertension, ischemic heart
disease, and arrhythmias.
 Drug Class Examples Mechanism of Action Clinical Use

Metoprolol, Block β1-receptors → ↓ HR and Chronic heart failure,

Beta-blockers
Propranolol contractility arrhythmias

Calcium channel Verapamil, Inhibit calcium entry into cardiac cells Atrial arrhythmias,
blockers Diltiazem → ↓ contractility hypertension

🔹 Clinical Considerations

✅ When to Use Inotropes:

 Low cardiac output states

 Shock states (especially cardiogenic, septic with myocardial depression)
 Postoperative cardiac surgery (e.g., pediatric open-heart surgery)
 Bridge to cardiac transplantation or mechanical support
 During cardiopulmonary resuscitation (CPR)

⚠️Risks of Inotropic Therapy:

 Increased myocardial oxygen consumption → ischemia or infarction

 Arrhythmias (especially ventricular)
 Hypotension (with vasodilating inotropes like milrinone)
 Peripheral ischemia (with vasoconstrictors like norepinephrine)
 Tolerance and receptor downregulation (with prolonged use)

🔹 Pediatric Considerations

In pediatric cardiac surgery (e.g., repair of congenital heart defects):

 Milrinone is often preferred for its vasodilatory and inotropic effects, especially useful
in low cardiac output syndrome (LCOS) post-surgery.
 Dopamine and dobutamine are common initial agents for mild-to-moderate myocardial
dysfunction.
 Epinephrine is added for more severe dysfunction or when hypotension is present.
 Monitoring includes:
o Continuous ECG and blood pressure
o Lactate levels
o Urine output
o Mixed venous oxygen saturation
🔹 Summary Flowchart: Inotrope Selection by Clinical Scenario
csharp
CopyEdit
[Cardiogenic Shock] → MAP >65?
↓ ↓
Yes No
Dobutamine Norepinephrine + Dobutamine/Epinephrine

[Septic Shock + myocardial dysfunction] → Norepinephrine + Dobutamine

[Post-cardiac surgery (low output)] → Milrinone ± Epinephrine

[Bradycardia with hypotension] → Dopamine or Isoproterenol

[Heart failure long-term (not acute)] → Avoid inotropes unless palliative

Would you like this in a printable table or handout format (e.g., for students or clinical rounds)? I
can also provide dosing guidelines or nursing considerations if needed.

Great! Here is a detailed guide on inotropic medications, including:

1. Common drugs and their doses

2. Infusion calculations
3. Titration and tapering protocols
4. Monitoring and nursing considerations

🔹 1. Common Inotropic Medications – Doses & Mechanisms

Drug Mechanism Typical Dose Range Route

Dobutamine β1-agonist → ↑ contractility 2–20 mcg/kg/min IV

Dose-dependent:
Low (1–3 mcg/kg/min): renal
Dopamine 2–20 mcg/kg/min IV
Mod (5–10): β1
High (>10): α1

Loading: 50 mcg/kg over 10 min

PDE3 inhibitor → ↑ contractility &
Milrinone Maintenance: 0.25–0.75 IV
vasodilation
mcg/kg/min

α1, β1, β2 agonist → ↑ HR, contractility, 0.01–0.5 mcg/kg/min (commonly

Epinephrine IV
vasoconstriction 0.05–0.1 in ICU)

Norepinephrine α1 > β1 agonist → vasoconstriction with 0.01–3 mcg/kg/min (start ~0.05) IV

 Drug Mechanism Typical Dose Range Route

mild inotropy

β1/β2 agonist → ↑ HR and contractility,

Isoproterenol 0.01–0.2 mcg/kg/min IV
↓ SVR

🔹 2. Drug Calculation Formula (Infusion Rate)

For most weight-based infusions, use the formula:

💡 Infusion Rate (mL/hr) = (Dose × Weight × 60) ÷ Concentration

Where:

 Dose = mcg/kg/min
 Weight = in kg
 Concentration = drug amount (mcg) per mL of solution

🧪 Example: Dobutamine

Order: Dobutamine at 5 mcg/kg/min

Weight: 20 kg
Concentration: 500 mg in 250 mL → 2000 mcg/mL

Calculation:
(5 × 20 × 60) ÷ 2000 = 6,000 ÷ 2000 = 3 mL/hr

🔹 3. Titration & Tapering Protocols

✅ Titration Guidelines

 Start at low dose and increase every 5–15 minutes based on clinical response.
 Always titrate to target MAP, urine output, perfusion, or cardiac output.

Drug Start Dose Titration Max Dose

Dobutamine 2.5 mcg/kg/min ↑ by 1–2.5 mcg/kg/min every 10–15m 20 mcg/kg/min

Dopamine 2 mcg/kg/min ↑ by 2 mcg/kg/min every 10–15m 20 mcg/kg/min

Milrinone 0.25 mcg/kg/min ↑ by 0.1 mcg/kg/min every 30–60m 0.75 mcg/kg/min

 Drug Start Dose Titration Max Dose

Epinephrine 0.01 mcg/kg/min ↑ by 0.01–0.05 mcg/kg/min every 5–10m 0.5 mcg/kg/min

Norepinephrine 0.01–0.05 mcg/kg/min ↑ by 0.02–0.05 mcg/kg/min every 5–10m 3 mcg/kg/min

⬇️Tapering Guidelines

 Reduce slowly, especially after long infusions (>12–24 hrs), to avoid rebound
hypotension or cardiac decompensation.
 Monitor BP, HR, UO, mental status, and lactate.
 Reduce by 10–20% every 30–60 minutes, depending on stability.
 Prefer tapering one inotrope at a time if using multiple agents.
 Always ensure patient is euvolemic and weaned from vasopressors first, before
stopping inotropes.

🔹 4. Monitoring During Inotropic Therapy

Parameter Goal

Heart rate Avoid >120 bpm (or based on age)

Blood pressure (MAP) ≥65 mmHg (adults), age-appropriate in peds

Urine output ≥0.5–1 mL/kg/hr

Lactate Decreasing trend (<2 mmol/L ideal)

ECG Monitor for arrhythmias

CVP/ScVO2 (if available) CVP: 8–12 mmHg, ScvO2 > 70%

Peripheral perfusion Warm extremities, cap refill <2 seconds

🔹 5. Nursing Considerations

 Administer via central line when possible (esp. vasopressors).

 Use dedicated line, avoid mixing with other drugs.
 Check IV patency hourly.
 Document dose, rate, vital signs, and response every 15–30 minutes during titration.
 Be prepared for rapid interventions for hypotension, arrhythmias, or extravasation.
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