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. • • • 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 • • • • 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 • • • • • • • • • • • • • • 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. • • • • • 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. • • • • • • 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 • • • • • 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 • • • • • • • • • • HTTPS://FRESHRN.TEACHABLE.COM/P/CARDIAC-NURSE-CRASH-COURSE/ • • • • •