7. Dobutamine
• Hemodynamic effects:
Improves cardiac output by improving stroke volume &
decreasing afterload with minimal tachycardia.
• Indications :
- Cardiogenic shock with normal BP
- Fluid refractory septic shock with normal BP and
impaired extremity perfusion
8. Side effects
• Increases myocardial oxygen consumption
leading to supply-demand mismatch.
• Tachycardia & arrhythmias.
10. NOTE
• At rates > 0.5, bp can ↑ but CO and organ
perfusion can worsen with a potential for
vulnerable organ ( gut, kidneys) iscemia
and failure. ( Numbers look better but
patients perfusion may be worse)
11. Indication
• Cardiogenic shock with decompensated shock
{ Improves diastolic BP, resulting in better coronary
perfusion & improved myocardial function }
• Myocardial dysfunction after cardiac arrest
• Cold septic shock refractory to fluids &
dobutamine/dopamine.
• Severe shock of any etiology
12. How to start and titrate
• Start infusion @0.1-0.3 mcg/kg/min.
• If BP improves but perfusion worsens add
inodilators
• Doses > 0.6 mics/kg/min are rarely useful as
ensuing organ ischemia may lead to MODS
15. Side effects
• ↑ Afterload { not appropriate in cardiogenic
shock}
• Worsens perfusion leading to multi organ
failure.
16. Vasopressin
• Potent pressor.
• Indication :
- Catecolamine resistant , vasodilatory
septic shock - after maximum NA(0.5-
1mcg/kg/min)
- Central DI
17. PDE inhibitors
• Results in increased cellular concentrations of
cAMP by inhibiting its destruction.
• Inotropy, lusitropy, vasodilatory with no
chronotropy resulting in improved
contractility,decreased preload & afterload.
• Synergestic effects with catecholamines
21. Sodium Nitroprusside(SNP)
• Produces arterial vasodilation resulting in
preload and afterload.
• Hemodynamics:
↓ SVR, ↓ PVR
Rapid half life of 2 mins
23. Levosimendan
• Calcium Sensitizer : New class of agent that
increases sensitivity of cardiac myofilament to
calcium .
• Inotropic and vasodilatory properties.
• Most extensively studied in acute heart
failure, but given the potential role for
abnormal calcium handling in sepsis-induced
myocardial depression, its use also has been
proposed in sepsis.
25. Care & Monitoring
• Tailored to desired hemodynamics response
• Cardiorespiratory monitoring in ICU
• Sideeffects if patient is hypovolumic or normal
cardiac function
• Rapid purge
• Freshly prepared solution
26. Vasoactive inotrope score
• Wernovsky et al and modified by
• Skippen and Krahn.
• 1 X dopamine (mics/kg per minute) + 1 X
dobutamine +15 X milrinone + 100 X
epinephrine +100 X norepinephrine +1000
X vasopressin (expressed as U/kg/per
minute).