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Vasopressors
CVT
83
Other
Professional
08/26/2012

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Cards

Term
Vasopressor and Vasodilators
Definition
• Norepinephrine (Levophed)
• Phenylephrine (Neo-synephrine)
• Dopamine (Intropin)
• Dobutamine (Dobutrex)
• Vasopressin (Pitressin)
• Nitroglycerin
• Morphine
• Sodium nitroprusside (Nipride)
• Hydralazine (Apresoline)
• Inamrinone (Inocor)
• Milrinone (Primacor)
• Digitalis (Digoxin, Lanoxin)
• Furosemide (Lasix)
Term
Norepinephrine (Levophed)
Definition
Mechanism of Action

Vasopressor & Sympathomimetic
Endogenous catecholamine
• Potent alpha-adrenergic receptor stimulation
• Increases myocardial contractility due to weaker beta-1 effects
• Arterial and venous vasoconstriction from potent alpha stimulation
• Increased SVR (afterload) increases blood pressure and may diminish cardiac output.
• Due to an increase in myocardial oxygen demand, may worsen myocardial ischemia, especially if coronary vasoconstriction is induced by coronary alpha receptor stimulation.
Term
Norepinephrine (Levophed)
Definition
Indications to Administer

• Hemodynamically significant hypotension refractory to other sympathomimetics
• Cardiogenic shock
• Used more often with low SVR states (e.g., sepsis) than in MI-related hypotension
Term
Norepinephrine (Levophed)
Definition
Contraindications

• Hypotension due to hypovolemia (may be used as a temporary agent until volume can be replaced)
• Profound hypoxemia or hypercarbia
• Mesenteric or peripheral vascular thrombosis
• Pre-existing hypertension
• Use with caution in patients with heart disease and/or hyperthyroidism.
Term
Norepinephrine (Levophed)
Definition
Side Effects

• Hypertension
• Arrhythmias (baroreceptor-mediated bradycardia)
• Chest pain
• Decreased peripheral perfusion
• Decreased renal perfusion (monitor urinary output and renal function)
Term
Norepinephrine (Levophed)
Definition
Dose

• Start at 0.5 - 1.0 mcg/min
• Titrate to desired effect (SBP of 90 - 100 mmHg); up to 30 mcg/min
• Adult dosage commonly 2 - 12 mcg/min
• Mix 4 ml ampule (1 mg/ml) in 500 ml D5W or 0.9% NSS to make 8 mcg/ml
Term
Phenylephrine (Neo-synephrine)
Definition
Mechanisms of Action

• Potent direct-acting sympathomimetic (synthetic) with strong alpha-adrenergic and weak beta-adrenergic cardiac stimulant properties
• Elevates systolic and diastolic pressures due to peripheral arteriolar constriction.
• Constricts capacitance vessels and increases venous return.
• Cardiac output is slightly decreased due to the increase in afterload.
• Coronary blood flow is increased.
• Rise in blood pressure may cause reflex bradycardia due to aortic baroreceptor stimulation.
• Produces little or no CNS stimulation
Term
Phenylephrine (Neo-synephrine)
Definition
Indications

• Hypotension from shock, shock-like states, or drug- induced shock
• To overcome PSVT
• During anesthesia to maintain adequate level of blood pressure  and  prolong  anesthesia  drug’s  effects
Term
Phenylephrine (Neo-synephrine)
Definition
Contraindications

• Severe coronary disease or hypertension
• Hypotension due to hypovolemia
• Ventricular tachycardia
• Cautious use in thyroid dysfunction, diabetes mellitus, myocardial disease, bradycardia, or cerebral atherosclerosis
Term
Phenylephrine (Neo-synephrine)
Definition
Adverse Reactions

• Sympathomimetic effects: palpitations, tachycardia, rebound bradycardia (especially in overdoses), extrasystoles, ventricular irritability, hypertension
• Tremors, dizziness, sleeplessness, headache, excitability
• Severe visceral or peripheral vasoconstriction and tissue necrosis if IV infiltrates
Term
Phenylephrine (Neo-synephrine)
Definition
Dose

• Titrate 0.1 - 0.18 mg/min until BP stabilizes, then 0.04 - 0.06 mg/min for maintenance infusion.
• Dilute 10 mg in 500 ml D5W or 0.9% NSS to make 0.2 mg/ml concentration.
Term
Dopamine (Inotropin)
Definition
Mechanisms of Action

VASOPRESSOR
• Chemical precursor of norepinephrine
• Low doses = dopaminergic receptor stimulation
• Vasodilation of renal, mesenteric, and cerebral arteries
• Urine output increased, while heart rate and blood pressure are usually unchanged
• Mid-range doses = beta-1 adrenergic receptor stimulation with weak alpha-stimulation
• Increased cardiac output due to increased heart rate and contractility
• Small increase in SVR
• Weaker alpha-1 at this dose antagonized by beta-1 stimulation
• High doses = alpha-adrenergic receptor stimulation
• Renal, mesenteric, and peripheral vasoconstriction
• Increase in SVR and preload
• Doses above 20 mcg/kg/min produce alpha stimulation similar to norepinephrine
• Increases myocardial work without compensatory increase in coronary blood flow
Term
Dopamine (Inotropin
Definition
Indications

• Cardiogenic shock
• Hemodynamically significant hypotension, in absence of hypovolemia (systolic blood pressure [SBP] < 70 mmHg)
• CHF, in combination with other agents (such as sodium nitroprusside)
Term
Dopamine (Inotropin)
Definition
Precautions

• Excessive vasoconstriction at high doses
• Can compromise circulation to the extremities in some patients (monitor peripheral pulses, color, and temperature).
• Will increase heart rate and may cause supraventricular or ventricular arrhythmias.
• Increased myocardial workload without increase in coronary perfusion can cause or worsen ischemia.
• Taper infusion carefully to avoid acute hypotension.
• Monoamine oxidase (MAO) inhibitors may potentiate effects of dopamine.
Term
Dopamine (Inotropin)
Definition
Contraindications

• Cardiogenic shock
• Uncorrected tachyarrhythmias
• Ventricular fibrillation
• Hemodynamically significant hypotension, in presence of hypovolemia (SBP < 70 mmHg)
Term
Dopamine (Inotropin)
Definition
Adverse Reactions

• Sympathomimetic stimulation: tachycardia, hypertension, ventricular ectopy, angina, anxiety, and decreased peripheral perfusion
• Headache
• Nausea and vomiting
• Decrease in pulse pressure
• Extravasation causes tissue necrosis and sloughing
Term
Dopamine (Inotropin)
Definition
Dose

• Low dose: 2 - 5 mcg/kg/min
• Mid-range dose: 5 - 10 mcg/kg/min
• High dose: > 10 mcg/kg/min
• Titrate dosage to desired hemodynamic effect, using data from right heart catheterization as measure of effects.
• Dilute 400 mg in 250 ml D5W for concentration of 1600 mcg/ml.
Term
Dobutamine (Dobutrex)
Definition
Mechanisms of Action

VASOPRESSOR
• Sympathomimetic with potent inotropic effects
• Stimulates beta-1 and alpha-adrenergic receptors
• Minor alpha stimulation antagonized by !stronger beta-1 effects
• Less likely to induce tachycardia at therapeutic doses than isoproterenol or dopamine
• Increase in renal and mesenteric blood flow due to increased cardiac output
• May be combined with dopamine to increase cardiac output, SVR, and preload.
• Decreases pulmonary occlusive pressures and peripheral resistance
• Myocardial work is balanced by increased coronary blood flow.
• Does not cause release of norepinephrine
Term
Dobutamine (Dobutrex)
Definition
Indications

• Hypotension with pulmonary congestion and dysfunction (e.g., CHF, cardiogenic shock)
• Hemodynamically significant hypotension (SBP of 70 - 100 mmHg)
• Drug of choice in low cardiac output states due to RV infarction
• Stress test echocardiography
Term
Dobutamine (Dobutrex)
Definition
Precautions

• Monitor for arrhythmias and fluctuations in blood pressure
• Insulin effects may be antagonized due to beta-2 stimulation in the pancreas
• Extravasation leads to tissue necrosis
• Cavity obliteration during dobutamine stress echocardiography (DSE)
• Due to myocardial thickening and increased contractility
• walls  may  “touch”  with  resultant  decrease  in  heart  rate  and   cardiac output
• May be alleviated by increasing preload (volume infusion)
Term
Dobutamine (Dobutrex)
Definition
Contraindications

• Idiopathic hypertrophic subaortic stenosis (IHSS)
• LVOT obstructions
• Tachydysrhythmias
• Pre-existing hypertension
• Shock due to hypovolemia
• Acute coronary syndrome with ventricular irritability
• Hypersensitivity to sympathomimetic amines
Term
Dobutamine (Dobutrex)
Definition
Adverse Reactions

• Tachycardia, arrhythmias, ventricular ectopy, palpitation, hypertension
• Anginal pain
• Peripheral vasoconstriction (may be countered with combined sodium nitroprusside infusion)
• Shortness of breath
• Nausea and vomiting
• Headache
• Anxiety, jitteriness
Term
Dobutamine (Dobutrex)
Definition
Dose

• Start at 0.5 mcg/kg/min IV and titrate to desired effect
• Usual dose is 2 - 20 mcg/kg/min
• Insertion of Swan-Ganz catheter for continuous pressure monitoring
• Titrate upward so as not to increase heart rate by greater than 10% (unless for stress echocardiogram).
• Dilute 1000 mg in 250 ml of D5W or 0.9% NSS for a concentration of 4 mg/ml.
Term
Vasopressin
Definition
Mechanisms of Action

ANTIDIURETIC & HEMOSTATIC• Anti-diuretic hormone
• Increases permeability of the renal tubular epithelium to adenosine monophosphate and water, promoting reabsorption of water and producing concentrated urine
• Cardiovascular effects related to potent alpha-adrenergic stimulation of vascular smooth muscles, leading to vasoconstriction and increased afterload
• Beneficial redistribution to coronary and cerebral vasculature without beta-1 induced increase in myocardial oxygen demand seen with epinephrine (cardiac arrest benefits)
Term
Vasopressin
Definition
Indications

• Cardiac arrest due to ventricular arrhythmias, asystole, or PEA (alternate to epinephrine)
• Hemodynamic support in vasodilatory shock (e.g. septic shock) refractory to more traditional therapy
• Esophageal variceal hemorrhage
Term
Vasopressin
Definition
Precautions

• Several drug interactions; consult drug reference or pharmacist (except in cardiac arrest)
• May provoke cardiac ischemia and angina
• Monitor for hypersensitivity reactions (urticaria, bronchoconstriction, angioedema, anaphylaxis).
Term
Vasopressin
Definition
Contraindications

• None during cardiac arrest
• Ischemic coronary artery disease or advanced arteriosclerosis
• Renal failure
Term
Vasopressin
Definition
Adverse Reactions

• Tremor, headache, vertigo
• Vasoconstriction with reduced peripheral perfusion
• Hypertension
• Arrhythmias, decreased cardiac output, myocardial ischemia
• Anginal chest pain
• Bronchoconstriction, respiratory congestion
• Abdominal cramps, nausea and vomiting, flatulence
Term
Vasopressin
Definition
Dose

• Cardiac arrest: single bolus of 40 units IV; use epinephrine if no response in 10 - 20 minutes
• Currently acceptable via endotracheal route; no set dosage as of current ACLS guidelines
Term
Nitroglycerin (NTG)
Definition
Mechanism of Action

• Antianginal & Vasodilator
• Nitrate smooth muscle relaxant
• Relieves angina via vasodilation of the venous system, which reduces venous return to the heart
• Causes a decrease in preload (ventricular volume, pressure, and wall stress); this decreases ventricular contractility and myocardial oxygen demand
• Dilates collateral circulation, including venous capacitance
• Dilates large coronary arteries and increases collateral blood flow to ischemic myocardial tissue
• Blocks vasospasm at the site of plaque rupture and increases collateral blood flow to ischemic myocardial tissues
• Sublingually, nitroglycerin decreases filling pressures without lowering SVR
• Cardiac output usually falls due to the decrease in preload
• When compared with sodium nitroprusside, nitroglycerin produces greater reduction in preload (venous return) and less reduction in afterload (arteriolar resistance)
Term
Nitroglycerin (NTG)
Definition
Precautions

• Patient must be seated or supine when administering nitroglycerin (especially sublingual doses).
• Continuous infusion should be via pump only and using appropriate tubing.
• When applying or removing ointment or paste, wear gloves to avoid accidental exposure.
Term
Nitroglycerin (NTG)
Definition
Contraindications

• Hypersensitivity to nitrate and nitrites
• Hypotension (SBP < 90 mmHg; cautious use in postural hypotension)
• Uncorrected hypovolemia
• Severe anemia
• Closed-angle glaucoma
• Intracranial bleeding or head trauma
• Cardiac tamponade
• Constrictive pericarditis
• Sildenafil or other phosphodiesterase-5 (PDE-5) inhibitor use within the preceding 48 hours
• Use with extreme caution in patients with inferior wall MI (likelihood of concomitant right ventricular infarction which requires maintenance of preload).
Term
Nitroglycerin (NTG)
Definition
Indications

• Drug of choice for acute angina pectoris attacks that are exertional or typical in nature (sublingual route)
• Unstable angina
• Prinzmetal’s  angina  (either  acutely  or  to  relieve  spasm  induced   during ergonovine studies)
• Acute myocardial infarction
• Congestive heart failure (lowers SVR and increases venous capacitance)
• Cardiogenic pulmonary edema
• Maintenance for chest pain prophylaxis (transdermal ointment)
Term
Nitroglycerin (NTG)
Definition
Adverse Reactions

• Headache (most common side effect; treat with aspirin or Tylenol)
• Hypotension (most severe side effect; treat with trendelenberg position and IV fluid bolus)
• Methemoglobinemia
• Change in hemoglobin configuration from
• Fe2+ to Fe3+ state
• Can result in refractory hypoxemia; usually related to high doses or longterm use
• Treated with methylene blue infusion
• Bradycardia (hypotension and bradycardia usually respond to IV fluids or atropine)
• Baroreceptor-mediated tachycardia, palpitations
• Nausea and vomiting
• Syncope or collapse
Term
Nitroglycerin (NTG)

Dose
Definition
Dose

Sublingually (SL):
• 0.3 - 0.4 mg tablet or metered spray every 5 minutes x 3 doses
• SL nitroglycerine (NTG) is drug of choice in angina or MI
• Evaluate pain scale and blood pressure before first dose and after each dose
• If sublingual NTG fails to relieve pain after three doses, patient should seek medical care ASAP.
• Intravenously:
• Start at 10 - 20 mcg/min and titrate until desired effect (pain free) is noted or to a maximum of 500 mcg/min.
• Bolus with 12.5 - 25.0 mcg, then start infusion
• Best for patients with unstable angina or for continuous treatment for AMI
• Dilute 40 mg with 250 ml D5W or 0.9% NSS for a concentration of 160 mcg/ml.
• Transdermal ointment:
• For chronic therapy, not for acute treatment of chest pain
• 1 - 2 inches of 2% paste applied to the chest wall
Term
Morphine sulfate
Definition
Mechanisms of Action

•Narcotic analgesic (Opiate)

• Schedule II narcotic (opioid) agonist analgesic and vasodilator derived from the opium poppy
• Naturally occurring narcotic analgesic
• Analgesic effects due to binding at various receptor sites, mimicking the effects of endogenous endorphins and enkephalins
• μ1: main action of this receptor is analgesia
• μ2: euphoria, respiratory depression, bradycardia, physical dependence, and ileus are elicited at this receptor
• Delta: modulates activity of mu receptors; it is thought that mu and delta receptors coexist as a complex
• Increases venous capacitance, reduces venous return, and decreases preload
• Decreases pulmonary congestion
• Reduces pulmonary capillary occlusive pressure
• Facilitates reabsorption of pulmonary edema from the alveoli to the vasculature
• Vasodilation decreases SVR at the arteriolar level and increases stroke volume, cardiac output, and decreases myocardial oxygen demand.
Term
Morphine sulfate
Definition
Indications

• Moderate to severe pain
• Pain and anxiety relief during acute MI
• Acute cardiogenic pulmonary edema (congestive heart failure)
Term
Morphine sulfate
Definition
Precautions

• Action is potentiated when used in combination with sedatives, hypnotics, or barbiturates.
• Narcotic effects can be reversed by naloxone.
• Encourage deep breathing, coughing, and frequent changes in position to minimize the risk of atelectasis
Term
Morphine sulfate
Definition
Contraindications

• Hypersensitivity to the drug
• Decreased level of consciousness
• Increased intracranial pressure or head trauma
• Convulsive disorders
• Hypotension
• COPD
• Chemical-irritant induced pulmonary edema (e.g., chlorine, ammonia)
• Ingested poisonings
• Chronic alcoholism
• Undiagnosed intra-abdominal or intracranial conditions
• Patients taking MAO inhibitors
Term
Morphine sulfate
Definition
Adverse Reactions

• Respiratory depression
• Hypotension (especially in patients with hypovolemia or increased SVR)
• Dose-dependent bradycardia due to vagal stimulation; may be blocked or reversed by use of an anticholinergic (such as atropine)
• Depression of cough reflex and respiratory status may induce atelectasis.
• Constipation and urinary retention
• Nausea and vomiting
• Hypothermia
• Localized allergic reaction with IV administration
• Addiction with long-term use
• High doses or overdose may cause:
• Anaphylaxis
• Cheyne-Stokes respiration or apnea
• Severe myocardial depression
• Tachycardia
• Death
Term
Morphine sulfate
Definition
Dose

•Dosage  varies  with  patient’s  size,  age,  and  renal   function.
• Start with 2 - 10 mg slow IV over 3-5 minutes.
• Titrate in small increments (1 - 3 mg) to desired effect, while maintaining adequate respiratory status.
Term
Sodium nitroprusside (Nipride)
Definition
Mechanisms of Action

• Vasodilator
• Anti-hypertensive

• Potent peripheral vasodilator, which affects arteriolar and venous smooth muscles (primarily arteriolar)
• Effects are seen immediately and resolve within minutes of infusion cessation
• Reduces blood pressure:
• Decreases SVR (afterload)
• Increases venous capacitance (preload)
• Increases cardiac output and enhances systolic emptying
Term
Sodium nitroprusside (Nipride)
Definition
Indications

• Hypertensive emergencies (drug of choice)
• Hypertensive emergency associated with neurologic dysfunction
• Treatment of failure (by decreasing preload and afterload, thus myocardial workload)
• Heart failure with pulmonary congestion refractory to diuretics
• Combined with dopamine to produce hemodynamic effects similar to dobutamine
Term
Sodium nitroprusside (Nipride)
Definition
Precautions

• Protect from light with foil and use immediately after mixing.
• Hemodynamic monitoring (arterial and right heart lines) is essential.
• Imbalance between coronary supply and demand may induce or worsen myocardial ischemia.
• Possible  coronary  “steal”
• May cause right-to-left shunt in presence of atrial septal defect (ASD) or ventricular septal defect (VSD), leading to hypoxia and cyanosis
• Sodium thiocyanate toxicity
• Metabolite from liver
• Most likely if used for over 72 hours
• Monitor patient for altered mental status
• Medication should be a faint yellow, not brown
• Long-term use may cause methemoglobinemia with resultant refractory hypoxemia.
• Prolonged use may cause hypothyroidism
• Reduce doses in the elderly
• Monitor arterial pressure and central venous pressure (CVP)
Term
Sodium nitroprusside (Nipride)
Definition
Contraindications

• Treatment of compensatory hypertension (A-V shunt or coarctation of the aorta)
• Known inadequate cerebral perfusion
• Use cautiously in renal or hepatic dysfunction
Term
Sodium nitroprusside (Nipride)
Definition
Adverse Reactions

• Usually occurs due to too rapid rate of infusion – reversible
• Hypotension (most common side effect; may induce or exacerbate ischemia)
• Nausea and vomiting
• Diaphoresis
• Headache
• Restlessness and apprehension
• Muscle twitching
• Palpitations
• Chest or abdominal pain
Term
Sodium nitroprusside (Nipride)
Definition
Dose

• Start infusion at 0.5 mcg/kg/min and titrate every 5 - 10 minutes to desired effect (SBP < 150 mmHg and/or DBP < 60 - 90 mmHg).
• Normal range is 0.5 - 8.0 mcg/kg/min.
• Mix 50 mg with 2 - 3 ml of D5W in the vial, then add 250 ml of D5W for a concentration of 200 mcg/ml.
Term
Hydralazine (Apresoline)
Definition
Mechanisms of Action

Class:
• Anti-hypertensive • Direct vasodilator

• Non-nitrate vasodilator and antihypertensive
• Reduces blood pressure mainly by direct effects on vascular smooth muscles of the arterioles, resulting in vasodilation
• Little effect on venous-capacitance vessels
• Diastolic response often greater than systolic
• Vasodilation reduces afterload and substantially improves cardiac output, as well as renal and cerebral perfusion.
• Hypotensive effect may be limited by sympathetic reflexes (increases in heart rate, stroke volume, and cardiac output).
Term
Hydralazine (Apresoline)
Definition
Indications

• Moderate to severe hypertension, including acute hypertensive emergency
• Pregnancy-induced hypertension and preeclampsia
• May be used in conjunction with cardiac glycosides or other vasodilators in short-term treatment of CHF
• Unexplained pulmonary hypertension
Term
Hydralazine (Apresoline)
Definition
Precautions

• Taper drug slowly to avoid sudden possible rise in blood pressure.
• Blood dyscrasia resulting in decrease in hemoglobin and hematocrit
• Obtain baseline and periodic BUN, creatinine, uric acid, serum potassium, blood glucose, and CBC; also obtain ECG.
• Use with caution if used concomitantly with beta-adrenergic blockers.
• Tartrazine may be contained in some products; may cause allergic-type reaction in patients who also have aspirin hypersensitivity.
Term
Hydralazine (Apresoline)
Definition
Contraindications

• Coronary artery disease or MI
• Pre-existing hypotension
• Persistent tachycardia
• Advanced renal impairment
• Mitral valve disease
Term
Hydralazine (Apresoline)
Definition
Adverse Reactions

• Headache and dizziness
• Palpitations and tachycardia
• Drug-induced hypotension
• Angina
• Nausea and vomiting, diarrhea, anorexia
• Decreased hematocrit and hemoglobin levels
• Hypersensitivity reactions: rash, urticaria, fever, chills, arthralgia, hepatitis, eosinophilia
Term
Hydralazine (Apresoline)
Definition
Dose

• Hypertension in adults:
• : 10 - 50 mg QID
• Intravenous: 5 - 40 mg slow IV push over 1 - 2 minutes, may repeat every 4 - 6 hours as needed
• Hypertension in geriatrics: start with 10 mg PO BID or TID and titrate as needed
Term
Inamrinone (Inocor)
Definition
Mechanisms of Action

Class : •Inotrophic agent

• Phosphodiesterase (PDE) inhibitor; noncatecholamine inotropic agent
• Formerly called amrinone
• Inhibits peak III cyclic AMP isoenzyme in cardiac and vascular muscle, resulting in direct inotropic effect and direct arterial vasodilation; effects are linked to inhibition of phosphodiesterase
• Drug acts slightly different than digitalis and beta- adrenergic stimulants.
• Rapid acting, potent inotropic (enhanced contractility) and vasodilator
• Cardiac output increases and SVR and preload decrease at dosages of 2 - 15 mcg/kg/min.
• Higher doses produce tachycardia.
• Hemodynamic effects are similar to dobutamine.
Term
Inamrinone (Inocor)
Definition
Indications

• Severe CHF refractory to diuretics, vasodilators, and conventional inotropic agents
• Additive to digitalis and catecholamine therapy
• Promotion of hemodynamic improvements in patients with CHF from ischemic heart disease
Term
Inamrinone (Inocor)
Definition
Precautions

• Clear yellow in appearance
• Store at room temperature and protect from light.
• May increase or induce myocardial ischemia
• Do not mix with furosemide or dextrose containing solutions.
• Adjust dosage frequently to achieve desired effect at the lowest possible dosage.
Term
Inamrinone (Inocor)
Definition
Contra- indications

• Hypersensitivity to inamrinone or bisulfites
• Pre-existing hypotension
• Presence of uncorrected aortic or pulmonic valve obstruction
• Right ventricular outflow tract (RVOT) or left ventricular outflow tract (LVOT) obstruction (IHSS)
• Patients with uncorrected hypokalemia or dehydration
Term
Inamrinone (Inocor)
Definition
Adverse Reactions

• Nausea and vomiting
• Thrombocytopenia due to hepatotoxicity (monitor platelet count daily)
• Dose-dependent tachydysrhythmias, ventricular irritability, hypotension
• Muscular stiffness, myalgias, tenderness, and localized inflammatory reaction at site of infusion
• Hypersensitivity reaction (itching) may occur with long-term use
• Fever
Term
Inamrinone (Inocor)
Definition
Dose

• Loading dose: 0.75 mcg/kg over 2-5 minutes
• Infusion at 5 - 10 mcg/kg/min, titrated to desired effect
• Adjust frequently to achieve optimal effects at lowest possible dose
• Mix 20 ml ampule of 100 mg (5 mg/ml) with 0.9% NSS for 1 - 3 mg/ml concentration
Term
Milrinone (Primacor)
Definition
Mechanisms of Action

Class: •Inotropic agent

• Phosphodiesterase (PDE) inhibitor; noncatecholamine inotropic agent
• Positive inotropic effect by increasing cellular levels of cAMP (inhibits peak III cyclic AMP isoenzyme in cardiac and vascular muscle)
• Results in direct inotropic effect (increased contractility) and vasodilation with little effect on chronotropic activity
• Vasodilation via direct relaxation of vascular smooth muscles with resultant reduction in afterload
• Overall improvement in myocardial contractility, ejection fraction, and cardiac output
Term
Milrinone (Primacor)
Definition
Indications

• Short-term treatment of CHF refractory to diuretics or digitalis
• To increase cardiac output and to reduce pulmonary capillary wedge pressure (PCWP) and SVR without increasing myocardial oxygen demand
• Chronic heart failure with decompensation
Term
Milrinone (Primacor)
Definition
Precautions

• Use cautiously in patients with atrial flutter or fibrillation due to shortening of AV nodal conduction time and potential for increased ventricular response.
• Avoid infusion in same IV line as furosemide (produces a precipitate).
• Monitor  vital  signs,  cardiac  monitor,  I&O’s,  renal  function,   and platelet levels.
• Expect dose reduction as cardiac output and urinary output improve.
Term
Milrinone (Primacor)
Definition
Contraindications

• Hypersensitivity to the drug
• Severe aortic and pulmonary valvular stenosis
• Hypertrophic cardiomyopathy
• Acute MI (initial phase)
• Hypotension
Term
Milrinone (Primacor)
Definition
Adverse Reactions

• Headache
• Ventricular ectopy, ventricular tachycardia (sustained or non-sustained), ventricular fibrillation
• Hypotension
• Chest pain and cardiac ischemia
• Thrombocytopenia (long-term therapy necessitates daily monitoring of platelet count)
• Local tissue discomfort and necrosis
Term
Milrinone (Primacor)
Definition
Dose

• Initial loading dose: 50 mcg/kg slow IVP over 10 minutes
• Continuous infusion: 0.375 - 0.75 mcg/kg/min
• Titrate dosage to maximum clinical effects (patient improvement, increase in urinary output, improvement in right-heart hemodynamics)
• Drug is commonly used concomitantly with digitalis and diuretics.
• In patients with renal impairment, the maximum dose is 1.13 mg/kg/day.
Term
Digitalis (Digoxin, Lanoxin)
Definition
Mechanisms of Action

Class: Antidysrhythmic
• Cardiac glycoside
• Mild positive inotropic effect due to increased calcium in the sarcoplasmic reticulum, increasing contractility
• Vasoconstriction of coronary and mesenteric arteries is due to increased calcium levels; increases SVR via increased vascular tone.
• Since digitalis effects are caused by increased calcium concentrations, betablockers have no effects on positive inotropic activity.
• Slows AV nodal conduction by lengthening the refractory period
• Increases aortic root baroreceptor sensitivity
• Results in reduction in heart rate due to increased arterial pressure
• High doses cause increased and potentially dangerous adrenergic activity (binds to muscle as well as in the plasma).
Term
Digitalis (Digoxin, Lanoxin)
Definition
Indications

Effective control of ventricular response in atrial tachydysrhythmias without adversely affecting contractility
• Calcium channel blockers may supplant digitalis as drug of choice for atrial fibrillation.
• If the BP is high, use calcium channel blocker.
• If the BP is normal or low, use digitalis.
• May convert PSVT to normal sinus rhythm
• Congestive heart failure
Term
Digitalis (Digoxin, Lanoxin)
Definition
Precautions

• Toxicity occurs in 20% of all patients
• Toxicity and overdose treated with Digoxin Immune Fab (Digibind)
• Hypokalemia
• Hypokalemia sensitizes the myocardium to digitalis.
• May alter onset and rate of positive inotropic effects
• Hyperkalemia possible in massive digitalis overdose.
• Causes massive coronary vasoconstriction
• May induce or worsen ischemia• Electrical cardioversion can be dangerous in the presence of digitalis toxicity.
• Can precipitate fatal ventricular arrhythmias
• Use lowest energy levels (10 - 20 joules)
• Hypercalcemia may also contribute to serious arrhythmias.
• Many drug interactions
• Verapamil and quinidine can double or triple serum levels of digitalis.
• Beta-adrenergic blockers may increase ectopic beats with digitalis on board.
• Concomitant presence of calcium chloride may increase risk of toxicity.
• Interactions also with loop, thiazine, and potassium-sparing diuretics
Term
Digitalis (Digoxin, Lanoxin)
Definition
Contra-indication

Ventricular tachycardia or ventricular fibrillation Acute myocardial infarction
High-degree AV blocks
Digitalis intoxication (relative)
WPW syndrome
Use with extreme caution if at all
Term
Digitalis (Digoxin, Lanoxin)
Definition
Adverse Reactions

Increases slope of phase 4 of the action potential
May induce delayed after-depolarizations in the Purkinje cells
Results in ectopy
Alters the ECG:
Increases the PR interval
Depresses the ST segment; characteristic ST segment scooped appearance
Flattens or inverts T waves Shortens the QT interval
• Shortens the QT interval
• Slows impulse transmission through the ventricular conduction system – development of reentry arrhythmias
• Wide range of cardiac arrhythmias: AV blocks, bi- directional ventricular tachycardia, paroxysmal atrial tachycardia with AV block, junctional rhythm and tachycardia, ventricular ectopy
• Extracardiac side effects
• Anorexia
• Nausea and vomiting
• Diarrhea
• Fatigue
• Mental status changes
• Blurred vision
• Yellow-green hue to visual spectrum
• Presence  of  “haloes”  around  lights
Term
Digitalis (Digoxin, Lanoxin)
Definition
Dose

• Loading dose: 10 - 15 mcg/kg
• IV effects in 5 - 30 minutes and peaks in 1.5 - 3.0 hours
• Maintenancedosingdependentonbodysizeand renal function (monitor creatinine clearance)
• Normal therapeutic range is 0.5 - 2.0 ng/ml.
• Alsoavailableinoralpreparations(0.125,0.25, and 0.50 mg tablets)
Term
Furosemide (Lasix)
Definition
Mechanisms of Action

Class: •Antihypertensive •Diuretic

• diuretic
• Inhibits the reabsorption of sodium and chloride in the proximal and distal tubules and in the loop of Henle
• Decreases renal vascular resistance; increases renal blood flow and urine output
Term
Furosemide (Lasix)
Definition
Indications

• Edema associated with CHF, cirrhosis of the liver, and renal disease
• Initiation of rapid diuresis in acute pulmonary edema
• Volume overload (intrinsic or extrinsic)
• Mild impairment in renal function
Term
Furosemide (Lasix)
Definition
Precautions

• Observe for signs of electrolyte disturbances
• Digitalis may exacerbate metabolic effects of hypokalemia.
Term
Furosemide (Lasix)
Definition
Contraindications

• Anuria (not beneficial in patients with renal failure)
• Hypersensitivity to sulfonamides
• Chronic metabolic alkalosis or hyperkalemia
• Hypotension or severe dehydration
Term
Furosemide (Lasix)
Definition
Adverse Reactions

• Electrolyte depletion: hypokalemia, hyponatremia
• Dehydration, hypotension
• Vascular thrombosis or embolism
• Hyperglycemia
• Nausea, vomiting, diarrhea, cramping
• Headache, vertigo, tremors
• Rash, urticaria
• Leukopenia, anemia
Term
Furosemide (Lasix)
Definition
Dose

• Intravenous: 20 - 80 mg IV, usually in increments of 20 mg
• Oral: 20 - 40 mg initially, titrated for effect
Term
Digitalis (Digoxin, Lanoxin)
Definition
Mechanisms of Action

Class: Antidysrhythmic
• Cardiac glycoside
• Mild positive inotropic effect due to increased calcium in the sarcoplasmic reticulum, increasing contractility
• Vasoconstriction of coronary and mesenteric arteries is due to increased calcium levels; increases SVR via increased vascular tone.
• Since digitalis effects are caused by increased calcium concentrations, betablockers have no effects on positive inotropic activity.
• Slows AV nodal conduction by lengthening the refractory period
• Increases aortic root baroreceptor sensitivity
• Results in reduction in heart rate due to increased arterial pressure
• High doses cause increased and potentially dangerous adrenergic activity (binds to muscle as well as in the plasma).
Term
Digitalis (Digoxin, Lanoxin)
Definition
Indications

• Effective control of ventricular response in atrial tachydysrhythmias without adversely affecting contractility
• Calcium channel blockers may supplant digitalis as drug of choice for atrial fibrillation.
• If the BP is high, use calcium channel blocker.
• If the BP is normal or low, use digitalis.
• May convert PSVT to normal sinus rhythm
• Congestive heart failure
Term
Digitalis (Digoxin, Lanoxin)
Definition
Precautions

• Toxicity occurs in 20% of all patients
• Toxicity and overdose treated with Digoxin Immune Fab (Digibind)
• Hypokalemia
• Hypokalemia sensitizes the myocardium to digitalis.
• May alter onset and rate of positive inotropic effects
• Hyperkalemia possible in massive digitalis overdose.
• Causes massive coronary vasoconstriction
• May induce or worsen ischemia• Electrical cardioversion can be dangerous in the presence of digitalis toxicity.
• Can precipitate fatal ventricular arrhythmias
• Use lowest energy levels (10 - 20 joules)
• Hypercalcemia may also contribute to serious arrhythmias.
• Many drug interactions
• Verapamil and quinidine can double or triple serum levels of digitalis.
• Beta-adrenergic blockers may increase ectopic beats with digitalis on board.
• Concomitant presence of calcium chloride may increase risk of toxicity.
• Interactions also with loop, thiazine, and potassium-sparing diuretics
Term
Digitalis (Digoxin, Lanoxin)
Definition
Contra-indication

Ventricular tachycardia or ventricular fibrillation Acute myocardial infarction
High-degree AV blocks
Digitalis intoxication (relative)
WPW syndrome
Use with extreme caution if at all
Term
Digitalis (Digoxin, Lanoxin)
Definition
Adverse Reactions

Increases slope of phase 4 of the action potential
May induce delayed after-depolarizations in the Purkinje cells
Results in ectopy
Alters the ECG:
Increases the PR interval
Depresses the ST segment; characteristic ST segment scooped appearance
Flattens or inverts T waves Shortens the QT interval
• Shortens the QT interval
• Slows impulse transmission through the ventricular conduction system – development of reentry arrhythmias
• Wide range of cardiac arrhythmias: AV blocks, bi- directional ventricular tachycardia, paroxysmal atrial tachycardia with AV block, junctional rhythm and tachycardia, ventricular ectopy
• Extracardiac side effects
• Anorexia
• Nausea and vomiting
• Diarrhea
• Fatigue
• Mental status changes
• Blurred vision
• Yellow-green hue to visual spectrum
• Presence  of  “haloes”  around  lights
Term
Digitalis (Digoxin, Lanoxin)
Definition
Dose

• Loading dose: 10 - 15 mcg/kg
• IV effects in 5 - 30 minutes and peaks in 1.5 - 3.0 hours
• Maintenancedosingdependentonbodysizeand renal function (monitor creatinine clearance)
• Normal therapeutic range is 0.5 - 2.0 ng/ml.
• Alsoavailableinoralpreparations(0.125,0.25, and 0.50 mg tablets)
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