ࡱ> ^`]7 6bjbjUU "\7|7|lLLLL X'88888&&&&&&&$y( *'u'88}'88&&R f 8, [^L2 f |'0': ,++++f Vasopressors, Inotropes, and Receptors.Oh My!!!!!!! By: JB Topol Pharm.D. Pharmacy Practice Resident 2008-2009 I believe the most frustrating piece of drug information for me to remember is the pharmacology and cardiovascular effects of the different vasopressors and inotropes. As a student on my ICU rotation at the VA, I learned a lot about how physicians decide on a particular agent and how different patients react differently to each medication. I felt it would be a good review to create charts regarding the different vasopressors/inotropes, their pharmacology, cardiovascular effects, and dosing. It can hopefully serve as a guide and a review for health professionals in an intensive care setting. I begin with a chart that depicts the different receptors, where they are located, and upon stimulation, what the overall net effect is. I was told in pharmacy school that in order to know how each drug affects the body that you have to understand the physiology behind the particular system being affected. The second chart depicts selected vasopressors/inotropes and the receptors on which they work. Milrinone and Vasopressin do not work within the alpha, beta, and dopamine receptor system. Milrinone, which is a phosphodiesterase inhibitor, causes a vasodilatation and increases the force of contraction. Vasopressin, on the other hand, is a direct vasoconstrictor working at the V1 receptors in the vascular smooth muscle and V2 receptors in the renal tubule causing the kidney to hold onto more water. The final chart depicts the dose and cardiovascular effects of selected vasopressors /inotropes. I hope this review was helpful and gave each of you a better understanding of the different vasopressors and inotropes. If you ever have questions about different agents and the pharmacology behind them, ask a pharmacist we are here to help. Adrenergic Receptors: Location and Effect Organ:ReceptorEffect of Stimulation:Heart:SA node1 and 2Increased automaticityAV node1 and 2Increased automaticity and conduction velocityAtria1 and 2Increased contractility and conduction velocityVentricles1 and 2Increased automaticity, contractility, and conduction velocityArterioles:Coronary and 2Vasoconstriction (+) and Vasodilatation (++)Skin and mucosaVasoconstriction (+++)Skeletal muscle and 2Vasoconstriction (++) and vasodilatation (++)CerebralVasoconstriction (+)Abdominal viscera and 2Vasoconstriction (+++) and vasodilatation (+)Pulmonary and 2Vasoconstriction (+)Renal, 1 and 2Vasoconstriction (+++) and vasodilatation (+)Veins, 1 and 2Vasoconstriction (++) and vasodilatation (++) Vasopressors and Inotropes: Receptor Specificity Drug:112DopaminergicCatecholamines:Dopamine: 1-3 ug/kg/min 3-10 ug/kg/min > 10 ug/kg/min - - +++ + ++++ ++++  - ++ + ++++ ++++ -Dobutamine+++++++Not ApplicableNorepinephrine++++++++++Not ApplicableEpinephrine: 0.01-0.05 ug/kg/min >0.05 ug/kg/min + ++++ ++++ +++ ++ +Not ApplicableIsoproterenolNo Activity++++++++Not ApplicablePhenylephrine+++++No ActivityNo ActivityNot ApplicableMilrinone*Not ApplicableNot ApplicableNot ApplicableNot Applicable Vasopressin**Not applicableNot ApplicableNot ApplicableNot Applicable* Milrinone is a phosphodiesterase inhibitor which causes vasodilatation and inotropic effects in the heart **Vasopressin works on the V1 receptor (vascular smooth muscle) and V2 (renal tubular collecting duct). Direct vasoconstrictor with no effects on the heart. Vasopressors and Inotropes: Dosing and Cardiovascular Effects Drug:Dose:CO:TPRMean BPRenal PerfusionHRMAPPCWPDopamine: 1-3 ug/kg/min 3-10 ug/kg/min > 10 ug/kg/min 1-20 mcg/kg/min NC ! ! NC NC/! ! NC NC ! !! !! !! ! !! !!!  NC ! ! NC NC/! !Epinephrine0.01-0.05 mcg/kg/min >0.05 ug/kg/minNC/! !! !! !!! !!! !!! !!NC/! !Dobutamine2-40 mcg/kg/min!!!NC!!!Norepinephrine0.01-0.3 mcg/kg/min!/NC!!!!!!Isoproterenol0.015-0.5 mcg/kg/min!!!!-with cardiogenic or septic shock. !-normal renal function!!!Phenylephrine10-200 mcg/min!!!!!!!MilrinoneLD: 50 mcg/kg over 10 minutes MD: 0.375-0.75 mcg/kg/min!!NC!NC/!NC/!!NC=No change, TPR=Total Peripheral Resistance, BP=Blood Pressure, HR=Heart Rate, CO=Cardiac Output, MAP=Mean Arterial Pressure, and PCWP=Pulmonary-Capillary Wedge Pressure. References Overgaard CB, Dzavik V. Inotropes and Vasopressors: Review of Physiology and Clinical Use Cardiovascular Disease. Circulation. 2008;118:1047-1056. London JA, Sena MJ. Pharmacologic Support of the Failing Heart. Surg Clin N Am. 2006;86:1503-1521. Lexi-comp. Available from www.lexi.com/online. Accessed 12/5/08. Also adapted from ICU dosing card, VA San Diego. 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