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Titration of Vasoactive medications

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TITRATION OF
VASOACTIVE
MEDICATIONS
INCREASING OR DECREASING A
VASOACTIVE DRUG OR OTHER CRITICAL
INFUSION FOR THERAPEUTIC EFFECT.
A CLASS OF DRUGS THAT INDUCE
ARTERIOLE VASOCONSTRICTION AND
THEREBY ELEVATE BLOOD PRESSURE.
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DRUGS THAT AFFECT THE STRENGTH OF
CONTRACTION OF HEART MUSCLE.
CHRONOTROPIC DRUGS MAY CHANGE
POSITIVE
THE HEART RATE AND RHYTHM BY AFFECTING
THE ELECTRICAL CONDUCTION SYSTEM OF
THE HEART AND THE NERVES THAT INFLUENCE
IT, SUCH AS BY CHANGING THE RHYTHM
PRODUCED BY THE SINOATRIAL NODE.
NEGATIVE
CHRONOTROPES
DECREASE HEART RATE
CHRONOTROPES
INCREASE HEART RATE
A DROMOTROPIC AGENT IS ONE
WHICH AFFECTS THE CONDUCTION
SPEED IN THE AV NODE AND
SUBSEQUENTLY THE RATE OF
ELECTRICAL IMPULSES IN THE HEART.
POSITIVE DROMOTROPY
INCREASES CONDUCTION
VELOCITY
(EPINEPHRINE STIMULATION),
NEGATIVE DROMOTROPY
DECREASES VELOCITY
(VAGAL STIMULATION).
THE BATHMOTROPIC EFFECT MODIFIES
THE HEART MUSCLE MEMBRANE
EXCITABILITY, AND THUS THE EASE OF
GENERATING AN ACTION POTENTIAL.
LUSITROPY IS THE RATE
OF MYOCARDIAL RELAXATION.
THE INCREASE
IN CALCIUM IN CARDIAC
MYOCYTES, VIA INCREASED
UPTAKE, LEADS TO INCREASED
MYOCARDIAL CONTRACTILITY
(POSITIVE
INOTROPIC EFFECT),
BUT THE MYOCARDIAL
RELAXATION, OR LUSITROPY,
DECREASES.
ANY OF A CLASS OF AROMATIC AMINES
THAT INCLUDES A NUMBER OF
NEUROTRANSMITTERS WHICH CAUSE
SYMPATHOMIMETIC ACTION
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LEFT VENTRICULAR END-DIASTOLIC PRESSURE
(LVEDP), IS THE AMOUNT OF VENTRICULAR
STRETCH AT THE END OF DIASTOLE. THINK OF IT AS
THE HEART LOADING UP FOR THE NEXT BIG
SQUEEZE OF THE VENTRICLES DURING SYSTOLE.
SOME PEOPLE REMEMBER THIS BY USING AN
ANALOGY OF A BALLOON – BLOW AIR INTO THE
BALLOON AND IT STRETCHES; THE MORE AIR YOU
BLOW IN, THE GREATER THE STRETCH.
AFTERLOAD, ALSO KNOWN AS THE SYSTEMIC
VASCULAR RESISTANCE (SVR), IS THE AMOUNT OF
RESISTANCE THE HEART MUST OVERCOME TO OPEN
THE AORTIC VALVE AND PUSH THE BLOOD VOLUME
OUT INTO THE SYSTEMIC CIRCULATION. IF YOU
THINK ABOUT THE BALLOON ANALOGY,
AFTERLOAD IS REPRESENTED BY THE KNOT AT THE
END OF THE BALLOON. TO GET THE AIR OUT, THE
BALLOON MUST WORK AGAINST THAT KNOT.
CARDIAC OUTPUT IS THE VOLUME OF BLOOD THE
HEART PUMPS PER MINUTE. CARDIAC OUTPUT IS
CALCULATED BY MULTIPLYING THE STROKE VOLUME
BY THE HEART RATE; NORMAL CARDIAC OUTPUT IS
ABOUT 4 TO 8 L/MIN, BUT VARIES DEPENDING ON
THE BODY’S METABOLIC NEEDS. CARDIAC INDEX
IS A CALCULATION OF THE CARDIAC OUTPUT
DIVIDED BY THE PERSON’S BODY SURFACE AREA
(BSA).
HAVING CHARACTERISTICS OF
SECRETING EPINEPHRINE OR SUBSTANCES
WITH SIMILAR ACTIVITY (EPINEPHRINE
AND NOREPINEPHRINE).
• VASCULAR WALLS (ARTERIES), HEART
• VASOCONSTRICTION
• INCREASE THE DURATION OF
CONTRACTION WITHOUT
INCREASING CHRONOTROPY (HEART
RATE)
• HEART
• INCREASE INOTROPY (FORCE OF
CONTRACTION) AND
CHRONOTROPY (HEART RATE) WITH
MINIMAL VASOCONTRICTION
• BLOOD VESSELS & LUNGS
• VASODILATION
• BROCHODILATION
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Note: Pharmacy prepares these medications
with only rare exceptions
ONE OF THE CATECHOLAMINES. SEVERAL SUBTYPES OF
DOPAMINE RECEPTOR THROUGHOUT THE BODY, EACH
WITH UNIQUE EFFECTS.
INTRAVENOUS DOPAMINE DOES DIFFERENT THINGS
DEPENDING ON THE DOSE.
• “RENAL DOSE DOPAMINE”
• 1 TO 5 MCG/KG/MIN
• STIMULATES DOPAMINERGIC RECEPTORS IN THE
RENAL BED, DILATES RENAL ARTERIES, INCREASES
RENAL BLOOD FLOW.
• INCREASES URINE PRODUCTION THROUGH
NATRIURESIS (NATRIURETIC HORMONE)
• 5 TO 10 MCG/KG/MINUTE
• STIMULATES BETA-1 RECEPTORS IN THE HEART. THIS
INCREASES IN CONTRACTILITY AND HEART RATE
(WHICH IN TURN WILL INCREASE CO AND USUALLY
BLOOD PRESSURE). AT THIS DOSE THE MEDICATION
ACTS MORE AS A POSITIVE INOTROPE.
• THIS DOSAGE RANGE REQUIRES A STEP-DOWN
UNIT/STAFFING
• GREATER THAN 10 MCG/KG/MINUTE
• STIMULATES ALPHA RECEPTORS IN THE PERIPHERAL
VASCULATURE, CAUSING VASOCONSTRICTION AND
AN INCREASE IN SVR, THUS INCREASING BLOOD
PRESSURE.
• AT THIS DOSE DOPAMINE ACTS AS A PRESSOR
• STEP-DOWN/ICU
• DOSE ADJUSTED BASED ON BLOOD-PRESSURE
• THE USUAL DOSAGE RANGE FOR DOPAMINE IS 1 TO
20 MCG PER KG PER MINUTE BY CONTINUOUS IV
INFUSION, ONSET OCCURS WITHIN 5 MINUTES, PEAK
TIME IS UNKNOWN, AND DURATION OF ITS ACTION
LASTS ABOUT 10 MINUTES AFTER DISCONTINUATION.
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BEFORE ADMINISTERING, CORRECT HYPOVOLEMIA AND ESTABLISH
GOAL BLOOD PRESSURE.
MONITOR BLOOD PRESSURE, HEART RATE AND RHYTHM EVERY FIVE
MINUTES DURING TITRATION.
MONITOR FOR TACHYARRHYTHMIAS.
INFUSE BY CENTRAL LINE IF POSSIBLE; IF PERIPHERAL, MONITOR IV SITE
ROUTINELY FOR EXTRAVASATION. TREAT SUSPECTED INFILTRATIONS
WITH PHENTOLAMINE.
CONSIDER ALTERNATE MEDICATION IF APPROACHING 20 MCG PER
KG PER MINUTE AND GOAL BLOOD PRESSURE IS NOT REACHED.
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TREAT THE EXTRAVASATION OF VASOPRESSORS INTO PERIPHERAL
TISSUES (E.G., DOBUTAMINE, DOPAMINE, EPINEPHRINE,
NOREPINEPHRINE, PHENYLEPHRINE, AND VASOPRESSIN).
DOSE:
• 5 MG IS DILUTED IN 10 ML NORMAL SALINE AND ADMINISTERED
S/C INTO THE INFILTRATED AREA AS SOON AS POSSIBLE
FOLLOWING THE EXTRAVASATION (WITHIN 12- HOURS).
IF DOSE EFFECTIVE, NORMAL SKIN COLOR SHOULD RETURN TO THE
BLANCHED AREA WITHIN ONE HOUR.
ELEVATE AFFECTED LIMB FOR 24 TO 48-HOURS.
APPLY LOCAL WARMING THERAPY FOR 15 TO 20 MINUTES,
EVERY 4-HOURS FOR 24 TO 48-HOURS.
• AFFECTS ALPHA RECEPTORS CAUSING PERIPHERAL
VASOCONSTRICTION, INCREASED BLOOD PRESSURE, AND
INCREASED SVR.
• THE DOSAGE IS 0.01 TO 0.3 MCG PER KG PER MINUTE BY
CONTINUOUS IV INFUSION, ONSET AND PEAK TIME ARE
IMMEDIATE WITH 1 TO 2 MINUTE DURATION OF EFFECT WHEN
INFUSION IS TURNED OFF.
• FIRST-CHOICE VASOPRESSOR FOR SEPSIS
• BEFORE ADMINISTERING, CORRECT HYPOVOLEMIA AND
ESTABLISH GOAL BLOOD PRESSURE.
• MONITOR BLOOD PRESSURE, HEART RATE, AND RHYTHM EVERY
FIVE MINUTES DURING TITRATION.
• INFUSE BY CENTRAL LINE IF POSSIBLE; IF PERIPHERAL, MONITOR
IV SITE ROUTINELY FOR EXTRAVASATION. TREAT SUSPECTED
INFILTRATIONS WITH PHENTOLAMINE.
• DO NOT MIX WITH NS. DO NOT MIX WITH ALKALINE AGENTS
(THOSE WITH A PH GREATER THAN 6.0, SUCH AS SODIUM
BICARBONATE, LIDOCAINE AND AMINOPHYLLINE).
• MONITOR FOR HEADACHE, NAUSEA, AND VOMITING,
BRADYCARDIA, CHEST PAIN, AND HYPERTENSION.
• HIGHER DOSES MAY BE NEEDED IF RECEPTORS ARE DOWNREGULATED, AS IN SEPSIS.
• VERY EFFECTIVE IN LOW-SVR; LESS EFFECT ON HEART RATE
THAN DOPAMINE; PREFERRED IN PRESENCE OF
TACHYARRHYTHMIA.
• DO NOT STOP INFUSION IN HYPOTENSIVE PATIENTS
• STIMULATES BETA1 (MYOCARDIAL)-ADRENERGIC RECEPTORS
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WITH RELATIVELY MINOR EFFECT ON HEART RATE OR PERIPHERAL
BLOOD VESSELS.
INOTROPE - INCREASED CARDIAC OUTPUT WITHOUT
SIGNIFICANTLY INCREASED HEART RATE.
DECREASES SYSTEMIC VASCULAR RESISTANCE
ONSET 1-2 MINUTES - PEAK 10 MINUTES
TREATMENT OF ACUTE HEART FAILURE IN THE CASE OF CARDIAC
SURGERY, SEPTIC, OR CARDIOGENIC SHOCK.
USED INTERMITTENTLY FOR TREATMENT OF CHF
STUDIES SUGGEST DOBUTAMINE EXERTS A PHYSICAL
CONDITIONING EFFECT SIMILAR TO EXERCISE…
IN SEVERE CHRONIC HEART FAILURE WEANING
PATIENTS FROM IV DOBUTAMINE CAN BE VERY
CHALLENGING.
• THE MOST COMMON ADVERSE REACTION WAS HEART RATE
INCREASED BY 30 BEATS PER MINUTE OR MORE.
• VENTRICULAR ECTOPIC ACTIVITY,
• NERVOUSNESS,
• HEADACHE,
• NAUSEA,
• VOMITING,
• PALPITATIONS
BOLD – STOP INFUSION, CALL PHYSICIAN
TYPICAL ORDER WILL BE FOR 2-20MCG/KG/MIN
REFER TO PHARMACY “GUIDELINES FOR IV
ADMINISTRATION
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• HTTPS://FRESHRN.TEACHABLE.COM/P/CARDIAC-NURSE-CRASH-COURSE/
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