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245110964565Effects00Effects57130951026795In shock, ? endogenous noradrenaline stores and downregular of beta-receptors, so alpha-receptors become more important; may need high doses in refractory shock00In shock, ? endogenous noradrenaline stores and downregular of beta-receptors, so alpha-receptors become more important; may need high doses in refractory shock47790101026795Overall00Overall31623001029970Heart00Heart21037551030605Vessels00Vessels20929601597660Vasodilation00Vasodilation20929601330325Vasoconstriction00Vasoconstriction246380330200Inotropes00Inotropes52266856610350?SVR, SBP, contractility, HR, CO ?DBP (variable)Bronchodilation00?SVR, SBP, contractility, HR, CO ?DBP (variable)Bronchodilation38938206609080+++Vasodilation (counteracts α) 00+++Vasodilation (counteracts α) 27520906612890++++Inotrope, chronotrope00++++Inotrope, chronotrope14573256610985+++VasoC, inotrope00+++VasoC, inotrope14484357267575Use in: cardiac arrest, anaphylaxis, asthma, septic shock, cardiogenic shock or low CO state, complete heart block (if atropine and transcutaneous pacing fail)Pros: preserves coronary and cerebral blood flow; improves myocardial blood flow during resus; stimulates spontaneous contractions ? defib success); 10% less arrhythmia than dopamineCons: ?renal / pulmonary / splanchnic flow; ?myocardial O2 consumption (negative effect on survival in post-resus state); metabolic acidosis ? ‘s efficacy (eg. Prolonged cardiac arrest); can cause lactic acidosis; tachyphylaxis; hyperglycaemia, hypokalaemia, hypophosphataemia, hypertension, intracranial haemorrhage, arrhthymia; careful in IHD; anxietyDose: 1mg in 1L N saline = 1mcg/ml Start at 0.5mcg/kg/min 1-20mcg/min 0.3-3mg/hr 0.1-2mcg/kg/min Cardiac arrest: 1mg Q3minly (high dose vs low dose = better ROSC with high dose, but no difference in survival) Anaphylaxis: 0.3 – 0.5mg IM 1:1000 repeat 100-200mcg (1.5-3mcg/kg) slow IV 1:100,000 bolus 0.1-1mcg/kg/min infusion Nebulised: 5ml (0.5ml/kgO 1:100000Use in: cardiac arrest, anaphylaxis, asthma, septic shock, cardiogenic shock or low CO state, complete heart block (if atropine and transcutaneous pacing fail)Pros: preserves coronary and cerebral blood flow; improves myocardial blood flow during resus; stimulates spontaneous contractions ? defib success); 10% less arrhythmia than dopamineCons: ?renal / pulmonary / splanchnic flow; ?myocardial O2 consumption (negative effect on survival in post-resus state); metabolic acidosis ? ‘s efficacy (eg. Prolonged cardiac arrest); can cause lactic acidosis; tachyphylaxis; hyperglycaemia, hypokalaemia, hypophosphataemia, hypertension, intracranial haemorrhage, arrhthymia; careful in IHD; anxietyDose: 1mg in 1L N saline = 1mcg/ml Start at 0.5mcg/kg/min 1-20mcg/min 0.3-3mg/hr 0.1-2mcg/kg/min Cardiac arrest: 1mg Q3minly (high dose vs low dose = better ROSC with high dose, but no difference in survival) Anaphylaxis: 0.3 – 0.5mg IM 1:1000 repeat 100-200mcg (1.5-3mcg/kg) slow IV 1:100,000 bolus 0.1-1mcg/kg/min infusion Nebulised: 5ml (0.5ml/kgO 1:10002451106614795Adrenalineβ > α 00Adrenalineβ > α 2463804448175Noradrenalineα > β00Noradrenalineα > β14585955065395Use in: vasodilatory shock (septic shock – proven to ?renal blood flow and urine output in sepsis; studies showed no difference when compared with adrenaline or dobutamine in septic shock; anaphylaxis) Cardiogenic shock with severe hypotension (increases CO at low dose)Pros: useful when loss of venous tone as no vasodilation; spares coronary circulationCons: ?renal / pulmonary / splanchnic flow; at high doses, ? HR may ? CO (dose-related reflex bradycardia); can cause ventricular arrhythmias; irritant with extravasationDose: 1mg in 1L N saline = 1mcg/ml Start at 0.5mcg/kg/min 1-20mcg/min 0.3-3mg/hr 0.1-2mcg/kg/min00Use in: vasodilatory shock (septic shock – proven to ?renal blood flow and urine output in sepsis; studies showed no difference when compared with adrenaline or dobutamine in septic shock; anaphylaxis) Cardiogenic shock with severe hypotension (increases CO at low dose)Pros: useful when loss of venous tone as no vasodilation; spares coronary circulationCons: ?renal / pulmonary / splanchnic flow; at high doses, ? HR may ? CO (dose-related reflex bradycardia); can cause ventricular arrhythmias; irritant with extravasationDose: 1mg in 1L N saline = 1mcg/ml Start at 0.5mcg/kg/min 1-20mcg/min 0.3-3mg/hr 0.1-2mcg/kg/min14585954444365++++VasoC, inotropeEffects ? with dose00++++VasoC, inotropeEffects ? with dose27533604446905++++Inotrope, chronotrope00++++Inotrope, chronotrope52279554443730?SVR, SBP, DBP, contractility, HR?CO at low dose?CO at high dose (?afterload)00?SVR, SBP, DBP, contractility, HR?CO at low dose?CO at high dose (?afterload)38950904443095Outweighed by β1 therefore no vasoD00Outweighed by β1 therefore no vasoD43402254088765β200β230835604071620β100β119246854025265α00α54076603011170Vasoconstriction and ? SVRNoradrenalineMetaraminolVasopressin00Vasoconstriction and ? SVRNoradrenalineMetaraminolVasopressin17621253011170Pump (inotrope)00Pump (inotrope)44780203011170Squeeze(vaso-pressor)00Squeeze(vaso-pressor)26917653011170? myocardial contractilityAdrenaline (bit of both)Dobutamine (bit of both)Isoprenaline00? myocardial contractilityAdrenaline (bit of both)Dobutamine (bit of both)Isoprenaline15881352567305D200D220929602649855?Noradrenaline release00?Noradrenaline release47790102197735? PVR00? PVR47790101930400?DBP + PVR00?DBP + PVR47790101597025?SBP + CO00?SBP + CO47790101321435?SBP00?SBP31515051597025+ inotrope and chronotrope00+ inotrope and chronotrope31515051324610+ inotrope00+ inotrope15881352259965D100D115982951991360β2β215976601668780β1β115982951271270α00α14401807450455Use in: vasodilatory shock; insufficient evidence to support use in cardiac arrestPros: increase coronary artery, cerebral and renal blood flowDose: 0.01 – 0.04iu/min in septic shockNo difference between vasopressin and adrenaline in cardiac arrest for ROSC, survival 24hrs, survival to discharge00Use in: vasodilatory shock; insufficient evidence to support use in cardiac arrestPros: increase coronary artery, cerebral and renal blood flowDose: 0.01 – 0.04iu/min in septic shockNo difference between vasopressin and adrenaline in cardiac arrest for ROSC, survival 24hrs, survival to discharge2336807141845Vasopressin00Vasopressin14408157137400V1; some α00V1; some α52101757137400VasoC00VasoC498983088188802273305095240Dopamine00Dopamine14344656014720Use in: cardiogenic shock with mild hypotension; trauma, sepsis, anaphylaxisCons: ?UO due to diuretic effect but doesn’t protect against ARF; arrhythmia; pulmonary vasoconstriction shunting ?paCO2; ?respiratory drive; nausea and vomiting; immune dysregulation; variable effects due to variable clearance; tissue ischaemia with extravasation; ? myocardial O2 consumption; tachyphylaxis at high doseDose: start at 5mcg/kg/min 10-50mg/hr 2-20mcg/kg/min 0.15-1.5mg/min00Use in: cardiogenic shock with mild hypotension; trauma, sepsis, anaphylaxisCons: ?UO due to diuretic effect but doesn’t protect against ARF; arrhythmia; pulmonary vasoconstriction shunting ?paCO2; ?respiratory drive; nausea and vomiting; immune dysregulation; variable effects due to variable clearance; tissue ischaemia with extravasation; ? myocardial O2 consumption; tachyphylaxis at high doseDose: start at 5mcg/kg/min 10-50mg/hr 2-20mcg/kg/min 0.15-1.5mg/min51949355701665? BP; ? HR00? BP; ? HR51949355393055? HR00? HR52038255090795?BP00?BP14306555701665High dose: α (vasoC, inotrope) 00High dose: α (vasoC, inotrope) 14325605393055Mod dose: β1 (inotrope and chronotrope) 00Mod dose: β1 (inotrope and chronotrope) 14344655090795Low dose: D1 (vasoD) and D2; β200Low dose: D1 (vasoD) and D2; β2498348067722752222503321050Dobutamine00Dobutamine14204953975100Use in: low CO state (eg. CCF, cardiogenic shock, RV infarct); mild hypotension (SBP 80-100)Pros: ?coronary perfusion; can be given via peripheral lineCons: may cause hypotension if volume deplete (combine with NAD to avoid); ?myocardial work; risk of myocardial ischaemia; has variable response, especially in the elderly and critically ill; ventricular ectopy at high doses; arrhythmiasDose: start at 5mcg/kg/min 10-50mg/hr 2-20mcg/kg/min 0.15-1.5mg/min00Use in: low CO state (eg. CCF, cardiogenic shock, RV infarct); mild hypotension (SBP 80-100)Pros: ?coronary perfusion; can be given via peripheral lineCons: may cause hypotension if volume deplete (combine with NAD to avoid); ?myocardial work; risk of myocardial ischaemia; has variable response, especially in the elderly and critically ill; ventricular ectopy at high doses; arrhythmiasDose: start at 5mcg/kg/min 10-50mg/hr 2-20mcg/kg/min 0.15-1.5mg/min4978400520319051987453316605? HR, CO ? SVR, afterload00? HR, CO ? SVR, afterload38709603315970++Vasodilation 00++Vasodilation 27292303319780++++Inotrope, chronotrope00++++Inotrope, chronotrope14344653317240+VasoC, inotrope00+VasoC, inotrope14204952545080Use in: refractory bradycardiaCons: can cause tachyarrhythmias; hypotension if hypovolaemia; increased myocardial O2 consumption; contraindicated in digitoxicityDose: 20-40mcg IV bolus 0.5-20mcg/min (0.05-1mg/hr)00Use in: refractory bradycardiaCons: can cause tachyarrhythmias; hypotension if hypovolaemia; increased myocardial O2 consumption; contraindicated in digitoxicityDose: 20-40mcg IV bolus 0.5-20mcg/min (0.05-1mg/hr)52038251885950? HR, CO ? COReflex bradycardia00? HR, CO ? COReflex bradycardia38709601885315++++Vasodilation 00++++Vasodilation 27292301889125++++Inotrope, chronotrope00++++Inotrope, chronotrope14344651886585N/A00N/A2222501890395IsoprenalinePure β 00IsoprenalinePure β 222250464820MetaraminolPure α 00MetaraminolPure α 14204951119505Use in: distributive shock; shock 2Y to tachycardiaPros: easy to administerCons: avoid in cardiogenic shockDose: 0.5-1mg boluses, or 1-5mg/hr infusion00Use in: distributive shock; shock 2Y to tachycardiaPros: easy to administerCons: avoid in cardiogenic shockDose: 0.5-1mg boluses, or 1-5mg/hr infusion5203825460375? SBP, afterload ? COVasodilation00? SBP, afterload ? COVasodilation3870960459740N/A 00N/A 2729230463550N/A00N/A1434465461010++++VasoC, inotrope00++++VasoC, inotrope3314706396355Septic Shock00Septic Shock16109956396355Surviving Sepsis Guidelines: 1st line = noradrenaline; 2nd line = adrenaline; vasopressin can be used concurrently, but not alone; can add in dobutamine if low CO despite high filling pressures, or persistent evidence of hypoperfusion despite good MAP (ie. Low CO but good “squeeze” already achieved)00Surviving Sepsis Guidelines: 1st line = noradrenaline; 2nd line = adrenaline; vasopressin can be used concurrently, but not alone; can add in dobutamine if low CO despite high filling pressures, or persistent evidence of hypoperfusion despite good MAP (ie. Low CO but good “squeeze” already achieved)3314705104130Cardiogenic Shock in CCF00Cardiogenic Shock in CCF16109955104130Aim to lower end-diastolic pressure and aid diuresisUsually will have high SVR due to endogenous catecholamines, hence vasodilation is usefulNeed to enhance CO, ?SVR, ?renal perfusion, improve diuresisAHA suggest dobutamine (low-mod dose) ?contractility, mild vasodilation Milrinone – RV afterload reduction via pulmonary vasodilation (therefore less ?in myocardial O2 demand); may cause ?BP so may need to be combined another inotrope00Aim to lower end-diastolic pressure and aid diuresisUsually will have high SVR due to endogenous catecholamines, hence vasodilation is usefulNeed to enhance CO, ?SVR, ?renal perfusion, improve diuresisAHA suggest dobutamine (low-mod dose) ?contractility, mild vasodilation Milrinone – RV afterload reduction via pulmonary vasodilation (therefore less ?in myocardial O2 demand); may cause ?BP so may need to be combined another inotrope3314703524250Cardiogenic Shock in MI00Cardiogenic Shock in MI16109953524250Will cause ?myocardial O2 consumption; can cause ventricular arrhythmias, contraction-band necrosis, infarct expansionHowever, hypotension ?myocardial perfusionUsed as bridge to definitive treatment measures – lowest possible dose should be usedRV infarction – try fluids first as “preload dependent”AHA suggest: 1st line – dobutamine if SBP 70-100 and no signs/symptoms of shock; dopamine if signs/symptoms of shock; a combination of the 2 at moderate dose may mitigate side effects; if SBP <70, noradrenaline; 2nd line, if NAD-resistant, vasopressin; dobutamine in RV infarct00Will cause ?myocardial O2 consumption; can cause ventricular arrhythmias, contraction-band necrosis, infarct expansionHowever, hypotension ?myocardial perfusionUsed as bridge to definitive treatment measures – lowest possible dose should be usedRV infarction – try fluids first as “preload dependent”AHA suggest: 1st line – dobutamine if SBP 70-100 and no signs/symptoms of shock; dopamine if signs/symptoms of shock; a combination of the 2 at moderate dose may mitigate side effects; if SBP <70, noradrenaline; 2nd line, if NAD-resistant, vasopressin; dobutamine in RV infarct31819854438650033147050165000 ................
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