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Inotropes, Vasopressors, and Chronotropes OH MY! A Review ..., Summaries of Pharmacy

Review the mechanism of action for vasopressors and inotropes. ▷ Recognize common side effects of different ... Contractility and chronotropic effects.

Typology: Summaries

2021/2022

Uploaded on 09/27/2022

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Inotropes, Vasopressors, and
Chronotropes OH MY! A
Review for the Young and
the Seasoned
MATT RUBERTUS, PHARMD
CLINICAL PHARMACY SPECIALIST CARDIOTHORACIC SURGERY/CRITICAL CARE
EMORY UNIVERSITY HOSPITAL
ATLANTA, GA
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Inotropes, Vasopressors, and

Chronotropes OH MY! A

Review for the Young and

the Seasoned

MATT RUBERTUS, PHARMD CLINICAL PHARMACY SPECIALIST – CARDIOTHORACIC SURGERY/CRITICAL CARE EMORY UNIVERSITY HOSPITAL ATLANTA, GA

Disclosure

 I have nothing to disclose pertaining to this presentation http://oz.wikia.com

Clinical Scenarios

 Shock  Cardiogenic  Vasodilatory  Sepsis  Cardiac Surgery  Valve Disease  Decompensated Heart Failure http://thefilmspectrum.com

Hypotension

Hypotension Baroreceptor Activation Decreased Renal Perfusion Increased Sympathetic Activity RASS Activation Cardiac Stimulation Vasoconstriction Volume Expansion Increased HR and Contractility Increased Preload Increased Cardiac Output Increased Systemic Vascular Resistance Increased Cardiac Output Increased Blood Pressure

Hemodynamics

Heart Rate Rate Rhythm Stroke Volume Preload CVP Contractility Afterload MAP

CO = X

Vasopressors http://thefilmspectrum.com

Beta Receptors

 Beta 1  Located in cardiac tissue  Contractility and chronotropic effects  Beta 2  Smooth muscle relaxation in bronchi and GI tract  Beta 3  Lipolysis – may be a target for weight loss

Vasopressin Receptors

 V

1 receptor causes vasoconstriction in vascular smooth muscle  V 2 receptor has an antidiuretic effect  V 3 receptor is responsible for endocrine functions

Norepinephrine

 Has effect on both alpha and beta receptors  Primarily alpha causing vasoconstriction  Beta activity less than other vasopressors  First line vasopressor in most clinical scenarios  SOAP-II trial  Recommended as first-line agent in surviving sepsis guidelines

Epinephrine

 Has both vasopressor and inotrope activity  Could be considered an “ino-pressor”

 Both alpha and beta activity

 Nearly equal on both  Important to know what the titration goal is!

Vasopressin

 Acts on vasopressin receptors to induce vasoconstriction  Differentiates from other vasopressors  Targeting alternate pathway may provide additional benefit  Potential for gut ischemia due to vasoconstriction in splanchnic circulation

Dopamine

 Spectrum of primary activity is dose dependent  Affects dopamine, beta, and alpha receptors  No longer considered a first line vasopressor in sepsis guidelines  Higher incidence of adverse effects than norepinephrine (SOAP II trial)

SOAP II Trial

N Engl J Med 2010;362:779- 89

SOAP II Trial

 All patients with shock were randomized for first-line vasopressor therapy  Dopamine: n = 858  Norepinephrine: n = 821  Over 60% of patients with septic shock  Primary outcome was 28 day mortality N Engl J Med 2010;362:779- 89