Vasopressors Table Rough properties by Target Receptor, Heart Rate/Inotropy, Systemic Vascular Resistance,

Vasopressors and Inotropes - Comparison Table Activity: Alpha-1, Beta-1, Dopamine, SVR, HR, CO, BP Phenylephrine Vasopressin Norepinephrine Epinephrine Dopamine Dobutamine Isoproterenol Milrinone - Dr. Eric Strong @DrEricStrong - Strong Medicine https://www.youtube.com/c/EricsMedicalLectures/ #Vasopressors #Inotropes #comparison #table #pharmacology #criticalcare

Clinician's Pocket Guide to Vasopressors - Receptor Profiles and Hemodynamic Parameters • Systemic Vascular Resistance - Circulatory pressure • Inotropy - Altered force of myocardial contractions • Chornotropy - Changes in the heart rate • MAP - Mean Arterial Pressure; indicates end organ perfusion (2*(Diastolic BP) + (Systolic BP)) / 3 • Cardiac Output - volume of blood pumped from each ventricle/min Norepinephrine Phenylephrine Epinephrine Dopamine Vasopressin #Vasopressors #Pharmacology #Summary #cheatsheet #management #comparison #table #receptors #inotropes

Vasopressors and Inotropes - Pharmacology Summary Vasopressors Phenylephrine (alpha-1) • Increases BP, SVR • Risk of reflex bradycardia due to increased MAP Norepinephrine (Levophed, alpha-1 / beta1, beta1 > beta2) • Increases BP, SVR, CO • Preferred first agent in shock Epinephrine (beta1 > beta2 / alpha1) • Increases HR, SVR, CO, BP • Higher doses cause more alpha-effect • 1st agent in anaphylaxis, 2nd line in septic shock Vasopressin (V1, V2) • Increases BP, SVR, not inotropic/chronotropic • V1, vessel constriction • V2 antidiuretic effect at kidney Dopamine (D1 > beta1 > alpha1) • Dose dependent receptor activation • D1 (1-2 mcg/kg/min): renal artery dilation • beta /mild alpha (5-10 mcg/kg/min): increases HR, contractility, CO • a (>10 mcg/kg/min): vasoconstriction, SVR Inotropes Dobutamine (beta1 > beta2 > alpha1) • Increases CO, less of a BP effect Milrinone (PDE3) • Phosphodiesterase inhibitor > increases cAMP/cGMP • Causes vasodilation and increased contractility - Rebecca Steinberg @RebeccaSteinb17 #Vasopressors #Inotropes #Pharmacology #Summary #management #medications

Shock and Vasoactive Drugs 1) Determine type and etiology of shock • Distributive: Sepsis, Anaphylaxis, Neurogenic • Cardiogenic: Acute MI, Acute Heart Failure, Valvular Disease, Mechanical Defect (papillary muscle rupture, VSD, etc.), Ventricular Arrhythmias / CHB • Hypovolemic: Bleeding, Extreme Dehydration, Severe Burns, Pancreatitis • Obstructive: Pericardial tamponade, Pulmonary embolism 2) Understand vasoactive drug pharmacology • Pure Vasoconstrictors: Vasopressin, Phenylephrine • Ino-Constrictors: Norepinephrine, Epinephrine, Dopamine • Ino-Dilators: Dobutamine, Isoproterenol, Milrinone • Pure Vasodilators: Nitroglycerin, Nitroprusside, Nesiritide 3) Treat shock & address underlying etiology Dr. Hasan Kazmi @hasankazmi01 #Vasopressors #shock #Vasoactive #Drugs #pharmacology #inopressors #diagnosis #management #comparison #table

$Vasopressor Receptor Activities alpha - beta1 - beta2 - DA - Vasopressin Dopamine (ug/kg/min) Epinephrine (ug/kg/min) Norepinqhrine (ug/min) Phenylephrine (ug/min) Vasopressin (units/min) #Vasopressors$

Vasopressor Receptor Activities alpha - beta1 - beta2 - DA - Vasopressin Dopamine (ug/kg/min) Epinephrine (ug/kg/min) Norepinqhrine (ug/min) Phenylephrine (ug/min) Vasopressin (units/min) #Vasopressors #Receptors #pharmacology #comparison #table #activity #criticalcare

Common Vasopressors and Inotropes Norepinephrine (NE) - Indication: Distributive shock (1st line for septic shock), Cardiogenic shock (mild ↑CO) - Side effects: Arrythmias, Peripheral ischemia Vasopressin - Indication: Distributive shock, Shock where ↑ HR is not desired (e.g., cardiogenic shock in patients with HCM) - Side effects: Peripheral ischemia, Splanchnic vasoconstriction Epinephrine - Indication: Anaphylactic shock (1st line), Refractory shock (distributive, septic), Bradyarrhythmias - Side effects: Arrhythmias, Peripheral ischemia Phenylephrine - Indication: Distributive shock (esp., vagally-mediated or med-induced), Shock where ↑ HR is not desired (e.g., cardiogenic shock in patients with HCM) - Side effects: Reflex bradycardia Dobutamine - Indication: Cardiogenic shock, Bradyarrhythmias, Some cases of septic shock - Side effects: Tachyarrhythmias, Cardiac ischemia Isoproterenol - Indication: Bradyarrhythmias - Side effects: Tachyarrhythmias, Cardiac ischemia Dopamine - Indication: Can be used in all types of shock, Bradyarrhythmias - Side effects: Tachyarrhythmias, Cardiac ischemia #Vasopressors #Inotropes #comparison #table #pharmacology #criticalcare

Vasopressors and Inotropes • Norepinephrine - Levophed - "Levo" - Generally thought of as the first pressor in most situations • Vasopressin - Pitressin - "Vaso" - Generally the second pressor added in shock • Epinephrine - Adrenalin - "Epi" - ACLS (1st), Anaphylaxis (1st), Symptomatic bradycardia, Shock (often adjunctive) • Phenylephrine - Neosynephrine - "Neo" - More common in OR; in MICU, often used as adjunctive pressor in refractory shock or specific situations (arrhythmia in setting of shock, HOCM, etc.) • Dopamine - Intropin - "Dopa" - Symptomatic bradycardia, Refractory shock (adjunctive pressor; studies have shown incr mortality compared to Levo. so generally not used 1st tine anymore) • Angiotensin - "Ang II" - Sepsis/distributive (refractory) • Methylene Blue - Refractory shock/vasoplegia, Post-cardiopulm bypass, Methemoglobinemia • Dobutamine - Dobutrex - Cardiogenic shock • Milrinone - Primacor - Cardiogenic shock Dr. Meredith Greer @EmmGeezee #Vasopressors #Inotropes #management #criticalcare #summary #comparison #table #pharmacology #indications

Push Dose Pressors - Mixing Instructions. EPINEPHRINE Has alpha and beta 1/2 effects so it is an inopressor Do not give cardiac arrest doses (1 mg) to patients with a pulse Mixing Instructions: • Take a 10 ml syringe with 9 ml of normal saline • Into this syringe, draw up I ml of epinephrine from the cardiac amp (Cardiac amp contains Epinephrine 100 mcg/ml) • Now you have 10 mls of Epinephrine 10 mcg/ml Onset-1 minute Duration-5-10 minutes Dose-0.5-2 ml every 2-5 minutes (5-20 mcg) PHENYLEPHRINE It is pure alpha, so no intrinsic inotropy, and no increase in heart rate, but increases in coronary perfusion can improve cardiac output. Mixing Instructions: • Take a 3 ml syringe and draw up 1 ml of phenylephrine from the vial (vial contains phenylephrine 10 mg/ml) • Inject this into a 100 ml bag of NS • Now you have 100 mls of phenylephrine 100 mcg/ml • Draw up some into a syringe; each ml in the syringe is mcg/ ml Onset-1 minute Duration- 10-20 minutes Dose-0.5-2 ml every 2-5 minutes (50-200 mcg) #Pharmacology #CriticalCare #PushDose #Vasopressors #PDPs #Epinephrine #Phenylephrine #Mixing #Instructions #Recipe

Emergency Treatment Algorithm for Convulsive Status Epilepticus 1. ABCDEFG (ABC's and Don't Ever Forget the Glucose) 2. Airway: lateral decubitus, nasal trumpets, 02, suction 3. IV access 4. Concurrently search for reversible cause First-line agents: - Lorazepam 0.1 mg/kg IV, max 4 mg, repeat once in 4 min or - Midazolam 10 mg IM once Second-line agents: - Levetiracetam 60 mg/kg IV (max 4500 mg) or - Fosphenytoin or Phenytoin 20 mg/kg IV (max 1500 mg) or - Valproate 40 mg/kg IV (3000 mg) Refractory medications in status epilepticus: - Propofol: 2-5 mg/kg IV, then infusion of 2-10 mg/kg/hr - Midazolam: 0.2 mg/kg IV, then infusion of 0.05-2 mg/kg/hr - Ketamine: 0.5-3 mg/kg IV, then infusion of 0.3-4 mg/kg/hr - Lacosamide: over 15 min, then 200 mg q12h PO/IV - Phenobaribital: 15-20 mg/kg IV at 50-75 mg/min - Consider consulting anesthesia for inhaled anesthetics #Convulsive #Status #Epilepticus #Treatment #Algorithm #Management #Neurology #Pharmacology

Management of Convulsive Status Epilepticus in children Stabilization Phase (Seizure 0-5 minutes): • Check and maintain ABC (airway, breathing and circulation). • Give high flow oxygen. • Check blood glucose level. • Establish Intravenous (IV) access. • Consider CBC, renal function test, serum electrolytes, blood culture and toxicology screening if appropriate. • Consider Antiepileptic Drug (AED) level. Early Status Epilepticus (Seizure 5-30 minutes): • IV Lorazepam 0.1 mg/kg (max: 4 mg) slowly over 2-5 minutes. OR • IV Diazepam 0.2 mg/kg (max: 10 mg) slowly over 2-5 minutes. If no IV access. consider: • Buccal Midazolam 0.5 mg/kg (max: 10 mg). OR • PR Diazepam 0.5 mg/kg (max: 20 mg). OR • IM Midazolam 0.2 mg/kg (max: 10 mg). (Do not give more than two doses of Benzodiazepines) Established Status Epilepticus (Seizure 30-60 minutes): • IV Phenytoin 20 mg/Kg (max: 1000 mg) infusion over 20 minutes with cardiac monitoring (if not on regular Phenytoin). If seizure continues: • IV Phenobarbitone 20 mg/Kg (max: 1000 mg) over 20 minutes. Alternative medications:- • IV Levetiracetam 20-60 mg/Kg (max: 2500 mg) over 20 minutes. OR • IV Valproic acid 20-40 mg/Kg (max: 3000 mg ) over 20 minutes. Refractory Status Epilepticus (Seizure more than 60 minutes): • Admit to PICU - Rapid sequence intubation • IV Midazolam Loading dose 0.15 mg/Kg (max: 8 mg) over 2-3 minutes, followed by continuous infusion of 2 mcg/Kg/minute, titrate to effect up to maximum of 24 mcg/Kg/minute. OR • IV Thiopental Sodium Loading dose 3 mg/Kg (max: 500 mg/dose) over 10 minutes, followed by continuous IV infusion of 3 mg/Kg/hour, titrate to effect up to maximum of 5 mg/Kg/hour. OR • IV Pentobarbital Loading dose 5 mg/Kg over 10 minutes, followed by continuous IV infusion of 0.5 mg/Kg/hour, titrate to effect up to maximum of 5 mg/Kg/hour. - Dr Ahmad khobrani @alkhobrani99 #Status #Epilepticus #seizure #Management #neurology #pediatrics #peds #algorithm