Calculation of infusion

Dose must be counterchecked in mcg/kg/min. Information needed: Dilution, weight, infusion rate.

Dose (mcg/kg/min) = Concentration (mcg/mL) x Infusion rate (mL/min) ÷ weight (kg) =x mcgy mL

xamLbmin

z kgDrug Dose1,6 CommentAdrenalineBradycardia

Hypotension/shock

IVI 2-10mcg/min Or 0.1-0.5mcg/kg/min, titrate.

IVI: 0.1-0.5mcg/kg/min, titrate.

β1> α1 , Low doses = β1+++ ,High doses = α1+++Continuous infcentral line. *Periextravasation1

Induce arrhythmias and myocardial ischemia, hyperglycemia, hyperlactanemia2

Reserved for depressed CO in conjunction with severe hypotension.3

DobutamineHeart Failure/Shock IVI 2.5-20mcg/kg/min. Titrate every few min

OR IVI 2.5mcg/kg/min, double dose every 15 min6

Max: 40mcg/kg/min

β1+++,β2++, α1+β2: Vasodilation, ↓systemic and pulmonary vascular resistance.2

May be preferred in patients with depressed CO, elevatedPCWP, and increased SVR with mild hypotension.2

Avoid in moderate or severe hypotension (eg, SBP< 80 mm Hg) because of the peripheral vasodilation.3

Adverse effects: hypotension and tachyarrhythmias3

DopamineShock

Heart Failure

IVI 1-5mcg/kg/min, up to 20mcg/kg/min,titrate.↑by 1-4mcg/kg/min at 10-30min intervalMax 50mcg/kg/min.

5-15mcg/kg/min, prefer lower dose.

1-5 mcg/kg/min: dopaminergic; 5-15mcg/kg/min: β1; >15 mcg/kg/min: α1

May be preferred in patients with depressed CO, normal or moderately elevated PCWP, and moderate or severe hypotension.2

>20mcg/kg/min may not have benefit on BP1

↑tachyarrhythmia, consider more direct acting vasopressor 1

Causes more tachycardia and may be more arrhythmogenic than norepinephrine4

NoradrenalineSepsisHypotension/shock

0.01-3mcg/kg/min OR8-12mcg/min, titrate. Usual MD: 2-4mcg/min OR0.1-0.5mcg/kg/min, titrate. (ACLS 2010)

α1++++, β1++Induce arrhythmias and myocardial ischemia2

Alkaline inactivate NE (eg. NaHCO3)1

Norepinephrine is more potent than dopamine and may be more effective at reversing hypotension in patientsw ith septic shock.4

Clinical applicationDrug of choice

Septic shock4,5 NoradrenalineAdrenaline (added to or substitute NE)Vasopressin (added to ↑MAP or to ↓ NE dose)Phenylephrine not recommended except:a) Noradrenaline is associated with serious arrhythmiasb)CO is known to be high and BP persistently low c) as salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target

Dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia)Dobutamine administered or added to vasopressor (if in use) in the presence of a) Myocardial dysfunction as suggested by elevated cardiac filling pressures and low CO, b)Ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP

Cardiogenic shock5,6,7 Dobutamine for patient with severe reduction in CO that vital organ perfusion is compromised.Noradrenaline for severely ill patients with marked hypotension (≤90mmHg) to raise BP and redistribute CO from the extremities to the vital organs.5,6 When SBP <85mmHg, consider non-vasodilating inotrope or vasopressor.6

Heart Failure7 DobutamineDopamine If UO <20ml/h with no response to doubling of dose of diuretic despite adequate left ventricular filling pressure (either inferred or measured directly) start IVI dopamine 2.5 µg/kg/min. Higher doses are not recommended to enhance diuresis6

MilrinoneAnaphylactic shock8 First choice: IM Epinephrine (adrenaline) 1:1,000 (1 mg/mL)for mg/kg, to a maximum of 0.5 mg (adult), 0.3 mg (child )

Refractory anaphylaxis: No clear superiority of dopamine, dobutamine, norepinephrine, phenylephrine, or vasopressin (either added to epinephrine alone, or compared with one another)

Reference:1. Lexi comp2. Applied therapeutic3. Medscape4. Surviving sepsis5. Management protocols in ICU. Malaysia. Published 20126. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European Heart Journal (2012) 33, 1787–1847.7. 2013 ACCF/AHA Guideline for the Management of Heart Failure. Circulation. 2013; 128: e240-e3278. World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis. WAO Journal, 2010; 4(2):13-37, February 2011