Understand the vasopressor and inotropic agent receptor physiology

Understand the vasopressor and inotropic agent receptor physiology

• Understand the vasopressor and inotropic agent receptor physiology

• Understand appropriate clinical application of vasopressors and inotropic agents

Vasopressors are class of drugs that elevate Mean Arterial Pressure (MAP) by inducing vasoconstriction.

• Vasopressors are class of drugs that elevate Mean Arterial Pressure (MAP) by inducing vasoconstriction.

• Inotropes increase cardiac contractility.

• Many drugs have both vasopressor and inotropic effects.

• Vasopressors are indicated for a decrease of >30 mmHg from baseline systolic blood pressure or MAP <60 mmHg, when either condition results in end-organ dysfunction secondary to hypoperfusion.

Main categories of adrenergic receptors relevant to vasopressor activity:

• Main categories of adrenergic receptors relevant to vasopressor activity:

• Alpha-1adrenergic receptor
• Beta-1, Beta-2 adrenergic receptors
• Dopamine receptors

72 year-old woman with DM type II, hypertension and Stage II CKD is transferred from a Skilled Nursing Facility for altered mental status. Her vitals upon arrival are as follows: Temp 101F, BP 70/45, Hr 140, RR 20, O2 Sat 95% RA. Pertinent lab findings: WBC 21, Cr 3.5, Lactic Acid 3.4, Positive UA.

• 72 year-old woman with DM type II, hypertension and Stage II CKD is transferred from a Skilled Nursing Facility for altered mental status. Her vitals upon arrival are as follows: Temp 101F, BP 70/45, Hr 140, RR 20, O2 Sat 95% RA. Pertinent lab findings: WBC 21, Cr 3.5, Lactic Acid 3.4, Positive UA.

• After adequate IVF resuscitation, pt continues to remain hypotensive BP 60-70s/30-40s and tachycardic Hr 130s. What is the most appropriate 1st line vasopressor/inotropic agent?

• A. Epinephrine (Adrenalin)
• B. Dobutamine
• C. Norepinephrine (Levophed)
• D. Dopamine

64 year-old man with PMH significant for CAD s/p MI and PCI (2004; drug-eluting stents), ischemic cardiomyopathy (EF 20-25%) with AICD (2007), who presents to ED with 1 week history of progressively worsening shortness of breath, orthopnea and bilateral lower extremity edema, after running out of all medications about 10 days ago.

• 64 year-old man with PMH significant for CAD s/p MI and PCI (2004; drug-eluting stents), ischemic cardiomyopathy (EF 20-25%) with AICD (2007), who presents to ED with 1 week history of progressively worsening shortness of breath, orthopnea and bilateral lower extremity edema, after running out of all medications about 10 days ago.

• In ED, vitals: Temp 99F, BP 75/48, Hr 75, RR 25, O2 Sat 91% on RA. CXR reveals vascular congestion and bilateral pleural effusion. Bedside ultrasound reveals significantly diminished EF.

• What is the most appropriate 1st line vasopressor/inotropic agent?

• A. Epinephrine (Adrenalin)
• B. Dobutamine
• C. Norepinephrine (Levophed)
• D. Dopamine

56 year-old obese man with PMH significant for COPD and OSA, who was initially admitted to the medicine floor for acute COPD exacerbation secondary to community-acquired pneumonia, was found to be in acute respiratory failure.

• 56 year-old obese man with PMH significant for COPD and OSA, who was initially admitted to the medicine floor for acute COPD exacerbation secondary to community-acquired pneumonia, was found to be in acute respiratory failure.

• Versed and Succinylcholine were given for emergent intubation. Vitals after intubation are as follows: Temp 99.8F, BP 74/48, Hr 74. What is the most appropriate 1st line vasopressor/inotropic agent?

• A. Phenylephrine (Neosynephrine)
• B. Dobutamine
• C. Norepinephrine (Levophed)
• D. Dopamine

• Understand the vasopressor and inotropic agent receptor physiology

• Alpha-1, Beta-1, and Beta-2 adrenergic receptors induce vasoconstriction, inotropy plus chronotropy, and vasodilation, respectively.
• Dopamine receptors induce vasodilation (one subtype induces norepinephrine release and vasoconstriction).

• Understand appropriate clinical application of vasopressors and inotropic agents.

• In hyperdynamic septic shock, norepinephrine or phenylephrine is first-line agent. Vasopressin as second-line agent to reduce need for other pressors.
• In cardiogenic shock, norepinephrine is preferred initial agent. After establishing adequate perfusion, Dobutamine added.
• In anaphylactic shock, 1st line agent is Epinephrine followed by Vasopressin as second line agent.
• Epinephrine is the 1st line agent in hypotension after CABG.
• In both neurogenic shock and anesthesia-induced hypotension, Neosynephrine is the 1st line agent.