INTRODUCTIONINTRODUCTION An inotrope is an agent, which increases or decreases An inotrope is an agent, which increases or decreases

the force or energy of the force or energy of muscular contractionsmuscular contractions.. In 1785 the first inotrope-Digitalis was discovered & In 1785 the first inotrope-Digitalis was discovered &

used for CCF.used for CCF. As science advanced, other inotropes were developed As science advanced, other inotropes were developed

which were more potent and have different chemical which were more potent and have different chemical properties and physiological effects.properties and physiological effects.

All inotropes are successful because they increase the All inotropes are successful because they increase the myocardial contractility of the heart.myocardial contractility of the heart.

By enhancing myocardial contractility, cardiac output, By enhancing myocardial contractility, cardiac output, the amount of blood ejected by the heart with each the amount of blood ejected by the heart with each beat, will also increase.beat, will also increase.

Three clinically approved Three clinically approved inotropesinotropesCardiac Glycosides: - Digitalis DerivativesCardiac Glycosides: - Digitalis Derivatives DigoxinDigoxinSympathomimetics: -Sympathomimetics: -

EpinephrineEpinephrineDopamine (Intropin)Dopamine (Intropin)Dobutamine (dobutrex)Dobutamine (dobutrex)Norepinephrine (levophed)Norepinephrine (levophed)Isoproterenol (isuprel)Isoproterenol (isuprel)

  Phosphodiesterase Inhibitors: -Phosphodiesterase Inhibitors: - Amrinone (Inocor)Amrinone (Inocor) Milirinone (Primacor)Milirinone (Primacor)

CARDIAC GLYCOSIDESCARDIAC GLYCOSIDES The first line of inotropes include all The first line of inotropes include all

digitalis derivatives digitalis derivatives Digitalis Glycosides haveDigitalis Glycosides haveA direct effect on cardiac muscle and the A direct effect on cardiac muscle and the

conduction system. conduction system. An indirect effect on the cardiovascular An indirect effect on the cardiovascular

system regulated by the system regulated by the autonomic nervous system which is autonomic nervous system which is

responsible for the effect on the sino-responsible for the effect on the sino-atrial (SA) and atrioventricular (AV) atrial (SA) and atrioventricular (AV) nodes.nodes.

The result of these direct and indirect effects The result of these direct and indirect effects are: -are: -

   An increase in force and velocity of An increase in force and velocity of

myocardial contractility (positive myocardial contractility (positive inotrope effect). inotrope effect).

Slowing of heart rate (negative Slowing of heart rate (negative chronographic effect). chronographic effect).

Decreased conduction velocity through Decreased conduction velocity through the AV node. the AV node.

Digoxin is the most commonly prescribed cardiac Digoxin is the most commonly prescribed cardiac glycosideglycoside

Convenient pharmacokinetics,Convenient pharmacokinetics, Alternative routes of administrationAlternative routes of administration Widespread availability of serum drug level Widespread availability of serum drug level

measurement. measurement.

DIGOXIN ADMINISTRATIONDIGOXIN ADMINISTRATION

Digoxin can be administered intravenously or Digoxin can be administered intravenously or orally.orally.

IV injection should be carried out over 15 IV injection should be carried out over 15 minutes to avoid vasoconstriction responses. minutes to avoid vasoconstriction responses.

Intramuscular Digoxin is absorbed Intramuscular Digoxin is absorbed unpredictably, causing local pain, and is not unpredictably, causing local pain, and is not recommended.recommended.

DIGOXINDIGOXIN

DIGOXIN LOADING DOSEDIGOXIN LOADING DOSE

Loading doses of Digoxin range from 10 – Loading doses of Digoxin range from 10 – 15mg/kg. 15mg/kg.

Digoxin can be given orally, but with a slower Digoxin can be given orally, but with a slower onset of action and peak effect.onset of action and peak effect.

  DIGOXIN MAINTENANCE DOSEDIGOXIN MAINTENANCE DOSE:-:- Initial therapy of Digoxin is usually started at Initial therapy of Digoxin is usually started at

0.125 to 0.375mg/day. 0.125 to 0.375mg/day.

  NOTE: DRAW A SERUM DIGOXIN LEVEL AT NOTE: DRAW A SERUM DIGOXIN LEVEL AT LEST SIX HOURS AFTER THE LAST DOSE!LEST SIX HOURS AFTER THE LAST DOSE!

SIDE EFFECTS ASSOCIATED WITH TOXICITY:-SIDE EFFECTS ASSOCIATED WITH TOXICITY:-

GASTROINTESTINALGASTROINTESTINAL: : Anorexia, nausea, Anorexia, nausea, vomiting, diarrhea vomiting, diarrhea Rare: Rare: abdominal pain, abdominal pain, hemorrhagic necrosis of the intestines.hemorrhagic necrosis of the intestines.

CNSCNS: : visual disturbances, (blurred or yellow visual disturbances, (blurred or yellow vision), headache, weakness, dizziness, vision), headache, weakness, dizziness, apathy and psychosisapathy and psychosis..

OTHEROTHER: : Skin rash, gynecomastiaSkin rash, gynecomastia

SYMPATHOMIMETICS (ADRENERGIC)SYMPATHOMIMETICS (ADRENERGIC)

Sympathomemetic drugs exert Sympathomemetic drugs exert potent inotropic effects bypotent inotropic effects by

stimulating beta (B1 and B2), alphastimulating beta (B1 and B2), alpha (A1 and A2) and dopaminergic (A1 and A2) and dopaminergic

receptors in the myocardium, blood receptors in the myocardium, blood vessels, and sympathetic nervous vessels, and sympathetic nervous system. system.

  

ALPHA 1 (A1):ALPHA 1 (A1):

A1 receptors are in vascular smooth muscle & also in A1 receptors are in vascular smooth muscle & also in the myocardium, which mediate positive inotropic the myocardium, which mediate positive inotropic and negative chronotropic effects.and negative chronotropic effects.

Stimulation of A1 receptors leads to vasoconstriction. Stimulation of A1 receptors leads to vasoconstriction.

ALPHA 2 (A2):- ALPHA 2 (A2):- A2 receptors are located in large blood vessels.A2 receptors are located in large blood vessels.

Stimulation of A2 receptors mediates arterial and Stimulation of A2 receptors mediates arterial and venous vasoconstriction.venous vasoconstriction.

BETA 1 (B1):- BETA 1 (B1):-

Beta 1 receptors increase heart rate and myocardial Beta 1 receptors increase heart rate and myocardial contractility.contractility.

BETA 2 (B2):-BETA 2 (B2):-

Beta 2 receptors enhance vasodilation; relax bronchial, Beta 2 receptors enhance vasodilation; relax bronchial, uterine and gastrointestinal smooth muscleuterine and gastrointestinal smooth muscle

  DOPAMINERGIC: DOPAMINERGIC: Related to the effect of dopamineRelated to the effect of dopamine..

DOPAMINE (INTROPIN)DOPAMINE (INTROPIN)(200mg/5ml ampule). (200mg/5ml ampule). 

A chemical precursor of epinephrine.A chemical precursor of epinephrine.

Possessing alpha and beta and dopaminergic Possessing alpha and beta and dopaminergic receptor – simulating actions. receptor – simulating actions.

The specific effects are related to the dose The specific effects are related to the dose delivered.delivered.

LOW DOSELOW DOSE

0.5- 2mcg/kg/minute (Dopaminergic effect).0.5- 2mcg/kg/minute (Dopaminergic effect).  Vasodilation of renal and mesenteric arteries.Vasodilation of renal and mesenteric arteries.

Promote blood flow and increased GFR Promote blood flow and increased GFR (glomerular filtration rates in patients who (glomerular filtration rates in patients who become resistant to diuretics). become resistant to diuretics).

Urine output may increase without significant Urine output may increase without significant effect on blood pressure or heart rate.effect on blood pressure or heart rate.

INTERMEDIATE DOSEINTERMEDIATE DOSE

2 to 10 mcg/kg/minute2 to 10 mcg/kg/minute

Beta-adrenergic receptor activity is Beta-adrenergic receptor activity is increased in the heart. increased in the heart.

Partial antagonism of alpha – Partial antagonism of alpha – adrenergic receptors will mediate adrenergic receptors will mediate vasoconstriction. vasoconstriction.

Modest increase in systemic Modest increase in systemic vascular resistance increases cardiac vascular resistance increases cardiac output & CVPoutput & CVP

DOPAMINE ADMINISTRATION DOPAMINE ADMINISTRATION

CONCENTRATIONSCONCENTRATIONS

Remove 5ml from 100ml 5% Remove 5ml from 100ml 5% Glucose ,add 200 mg Dopamine, final Glucose ,add 200 mg Dopamine, final concentration 2000mcg/ml.concentration 2000mcg/ml.

OROR

Make the concentration half with 50 ml Make the concentration half with 50 ml of 5% Dextrose.of 5% Dextrose.

Indication:-Indication:- Renal protection.Renal protection. Hypotention/haemodynamic Hypotention/haemodynamic compromise due to MI, trauma, compromise due to MI, trauma, sepsis, CCF.sepsis, CCF. Increases mesenteric flow in Increases mesenteric flow in mesenteric ischaemia.mesenteric ischaemia.

Contraindication: -Contraindication: -Pregnancy.Pregnancy.Phaeochromocytoma.Phaeochromocytoma.Tachyarrhythmias.Tachyarrhythmias.Occlusive vascular disease.Occlusive vascular disease.

WARNING:WARNING: Correct hypovolaemia prior to administration.Correct hypovolaemia prior to administration. Do not infuse peripherally.Do not infuse peripherally. Extravasations can cause severe tissue necrosis.Extravasations can cause severe tissue necrosis. Monitor the patient carefully for decreased Monitor the patient carefully for decreased circulation in the extremities.circulation in the extremities.

If extravasates into tissues-If extravasates into tissues-The infusion should be immediately stopped.The infusion should be immediately stopped.Infiltrate with 0-15ml 0.9% Sodium Chloride Infiltrate with 0-15ml 0.9% Sodium Chloride

containing 5-10mg containing 5-10mg Phentolalmine.Phentolalmine.Regitine Regitine is then administered SQ in the four is then administered SQ in the four

90°quadrants around the site of extravasations90°quadrants around the site of extravasations..

ADVERSE EFFECTS:ADVERSE EFFECTS:Tachycardia Tachycardia Supraventricular tachycardia Supraventricular tachycardia Ventricular arrhythmias Ventricular arrhythmias Pulmonary congestion Pulmonary congestion Nausea Nausea VomitingHeadache.Headache.Increased myocardial oxygen demand.Increased myocardial oxygen demand.Hypotension when used concomitantly Hypotension when used concomitantly

with dilantin with dilantin

DOBUTAMINE (Dobutrex)DOBUTAMINE (Dobutrex)(250mg in 20ml ampule)(250mg in 20ml ampule)

• Drug class:-Drug class:- Catecholamine.Catecholamine.• Mechanism of action:-Mechanism of action:-

Chemically related to dopamine.Chemically related to dopamine. Synthetic catecholamine.Synthetic catecholamine. Stimulates Beta 1 and Alpha-adrenergic Stimulates Beta 1 and Alpha-adrenergic

receptors.receptors. Increases myocardial contractility, stoke volume Increases myocardial contractility, stoke volume

and cardiac output.and cardiac output. Decreases preload and afterload (Vasodilatation)Decreases preload and afterload (Vasodilatation) Produces mild chronotropic, hypotensive and Produces mild chronotropic, hypotensive and

arrhythmogenic effects.arrhythmogenic effects. Increase renal and mesenteric blood flow by Increase renal and mesenteric blood flow by

increasing cardiac output.increasing cardiac output. Does not affect renal blood flow like dopamine.Does not affect renal blood flow like dopamine.

• Initial dose: - Initial dose: -

2 to 3 mcg/kg/minute.2 to 3 mcg/kg/minute.

• Usual dose: -Usual dose: -

2.5 to 10 mcg/kg/minute.2.5 to 10 mcg/kg/minute.

• Desired effects include:Desired effects include:

1. Increased cardiac output1. Increased cardiac output

2. Increased stroke volume2. Increased stroke volume

This dose will not increase heart rate This dose will not increase heart rate or cause vasoconstriction.or cause vasoconstriction.

Maximum dose: -Maximum dose: -

20 mcg/kg/minute.20 mcg/kg/minute.Dobutamine administration Dobutamine administration

concentrations: -concentrations: -

Infusion pump: 500 mg per 250 cc Infusion pump: 500 mg per 250 cc normal salinenormal saline

Syringe pump: 250 mg (20cc) in Syringe pump: 250 mg (20cc) in total 50 cc normal total 50 cc normal

saline (5 mg per cc)saline (5 mg per cc)

• Contraindication:-Contraindication:-

Idiopathic hypertrophic subaortic Idiopathic hypertrophic subaortic stenosis.stenosis.

• Nursing implication: -Nursing implication: -Monitor for hypertension, tachycardia, chest pain, Monitor for hypertension, tachycardia, chest pain,

and premature ventricular contractions.and premature ventricular contractions.Monitor cardiac output, pulmonary artery pressure Monitor cardiac output, pulmonary artery pressure

ECGECGCorrect hypovolemia before treating with this Correct hypovolemia before treating with this

drug.drug.Patient with aterial fibrillation should be Patient with aterial fibrillation should be

digitalized before giving this drug to prevent digitalized before giving this drug to prevent ventricular tachycardia.ventricular tachycardia.

Warning: - Warning: - Increasing the rate past 20 Increasing the rate past 20

mcg/kg/minute could be detrimental mcg/kg/minute could be detrimental because myocardial oxygen because myocardial oxygen consumption can cause tachycardias.consumption can cause tachycardias.

Adverse effects:-Adverse effects:-Tachycardia Tachycardia

Arrhythmias Arrhythmias Blood pressure fluctuation Blood pressure fluctuation Myocardial ischemia Myocardial ischemia Headache Headache Nausea Nausea Tremors Tremors HypokalemiaHypokalemia

NOREPHINEPHRINE (LEVOPHED)NOREPHINEPHRINE (LEVOPHED)

Drug class: -Drug class: - Catecholamine.Catecholamine. Endogenous catecholamine released from nerve cells, Endogenous catecholamine released from nerve cells,

synthesized by adrenal medulla.synthesized by adrenal medulla. Metabolized mainly by the liver.Metabolized mainly by the liver.Mechanism of action: -Mechanism of action: -

Potent alpha – receptor antagonist, leads to arterial and Potent alpha – receptor antagonist, leads to arterial and venous constriction. venous constriction.

Minimal effect on beta 2 receptors. Minimal effect on beta 2 receptors. Increases myocardial contractility due to its beta 1 Increases myocardial contractility due to its beta 1

adrenergic effects. adrenergic effects. Effective in septic shock and neuroginic shock after Effective in septic shock and neuroginic shock after

adequate hydration.adequate hydration.Increases blood flow to the major organs including the Increases blood flow to the major organs including the

kidneys and helps in increases urine output.kidneys and helps in increases urine output.

Initial dose: -Initial dose: -

0.5 mcg/minute to 1 mcg/minute0.5 mcg/minute to 1 mcg/minute

Titrate to desired effectTitrate to desired effect    Average dose:-Average dose:-

2 to 12 mcg/minute2 to 12 mcg/minute

Doses greater than 30 mcg/minute Doses greater than 30 mcg/minute

might be required during shock.might be required during shock.

Norepinephrine administration Norepinephrine administration concentration:-concentration:-

Infusion pump: 4 mg per 250 c crystalloid Infusion pump: 4 mg per 250 c crystalloid (16 mcg/cc)(16 mcg/cc)

Contraindications:-Contraindications:-Hypovolemic and cardiogenic shock Hypovolemic and cardiogenic shock (because potent vasoconstriction is (because potent vasoconstriction is already occurring).already occurring).

Pregnancy.Pregnancy.Hypoxia.Hypoxia.Hypovolemia secondary to fluid Hypovolemia secondary to fluid deficit.deficit.

Caution with hypertension and Caution with hypertension and hyperthyroidism.hyperthyroidism.

Nursing implication:-Nursing implication:-

Extravasations produces ischemic Extravasations produces ischemic necrosis and sloughing of superficial necrosis and sloughing of superficial tissues.tissues.

Use of a central line is recommended Use of a central line is recommended due to the risk of extravasations into due to the risk of extravasations into surrounding tissue.surrounding tissue.

Rebound hypotension occurs if it is Rebound hypotension occurs if it is discontinued abruptly.discontinued abruptly.

Its use should be temporary.Its use should be temporary.Monitor for bradycardia or Monitor for bradycardia or

arrhythmias.arrhythmias.

EPINEPHRINEEPINEPHRINE

• Drug class: -Drug class: -

Catecholamine.Catecholamine.

Endogenous catecholamine, produced, Endogenous catecholamine, produced,

stored, and released by the adrenal stored, and released by the adrenal medulla.medulla.

Mainly eliminated via kidneys.Mainly eliminated via kidneys.

• Mechanism of action: -Mechanism of action: -Stimulation of alpha and beta-adrenergic Stimulation of alpha and beta-adrenergic

receptors causes vasoconstriction.receptors causes vasoconstriction.Increases heart contractility and rate.Increases heart contractility and rate.Causes bronchodilation.Causes bronchodilation.Antagonizes histamine effect.Antagonizes histamine effect.

• Dosage: -Dosage: - Initial dose 0.5-1mg IV.Initial dose 0.5-1mg IV. Or Or 1.5-3mg via ETT.1.5-3mg via ETT. Maintain drip of 1-4 Maintain drip of 1-4

mcg/minute. Titrate to BP.mcg/minute. Titrate to BP.Common contraindication: -Common contraindication: -

Hypertension.Hypertension.Pheochromocytoma.Pheochromocytoma.Caution with heart failure angina and Caution with heart failure angina and

hyperthyroidism.hyperthyroidism.

Adverse effects: -Adverse effects: -Cardiac Arrhythmias Cardiac Arrhythmias Palpitations Palpitations TachycardiaTachycardia SweatingSweating Nausea and vomitingNausea and vomitingRespiratory difficultyRespiratory difficultyPallorPallorDizzinessDizzinessWeaknessWeaknessTremorsTremorsHeadacheHeadacheApprehensionApprehensionNervousnessNervousness AnxietyAnxiety

Nursing implication: -Nursing implication: -Monitor ECG.Monitor ECG.Observe for ventricular ectopy.Observe for ventricular ectopy.

ISOPROTERENOL (ISUPREL)ISOPROTERENOL (ISUPREL)  

Has nearly pure beta-adrenergic receptor activity. Has nearly pure beta-adrenergic receptor activity. Increase heart rate and contractility and cause Increase heart rate and contractility and cause

peripheral vasodilation.peripheral vasodilation. Used for temporary control of symptomatic Used for temporary control of symptomatic

bradycardia. bradycardia. Initial drug of choice for heart transplant.Initial drug of choice for heart transplant. Increases myocardial oxygen requirements and the Increases myocardial oxygen requirements and the

possibility of inducing or exacerbating myocardial possibility of inducing or exacerbating myocardial ischemia is present. ischemia is present.

The risk of arrhythmias is also increased. The risk of arrhythmias is also increased. It is not the first treatment of choice for It is not the first treatment of choice for

bradycardias.bradycardias.

• Atropine, epinephrine or pacing should be Atropine, epinephrine or pacing should be initiated first.initiated first.

DOSE: -DOSE: - Initial dose of 2 mcg/minuteInitial dose of 2 mcg/minute    Titrate dose to a maximum of 10 mcg/min. Titrate dose to a maximum of 10 mcg/min.

or heart rate is 60 or greater. or heart rate is 60 or greater. Decrease the rate if blood pressure is Decrease the rate if blood pressure is

>120/60 >120/60 Decrease rate if PVC’s or Ventricular Decrease rate if PVC’s or Ventricular

tachycardia is noted. tachycardia is noted.

Isoporterenol administration Isoporterenol administration concentration: -concentration: -    1 mg in 250 cc crystalloid (4 mcg/cc).1 mg in 250 cc crystalloid (4 mcg/cc).

Adverse effects: -Adverse effects: -Arrhythmias. Arrhythmias. Ventricular tachycardia. Ventricular tachycardia. Ventricular fibrillation.Ventricular fibrillation.

WarningWarning:-:- May exacerbate tachyarrhythmias May exacerbate tachyarrhythmias

due to digitalis toxicity.due to digitalis toxicity. May precipitate hypokalemia.May precipitate hypokalemia.

  PHOSPHODIESTERASE INHIBITORSPHOSPHODIESTERASE INHIBITORS

   Powerful positive inotropic agents. Powerful positive inotropic agents.

The action is not fully understood. The action is not fully understood. Inhibits phosphodiesterase, an enzyme that degrades Inhibits phosphodiesterase, an enzyme that degrades

(CAMP) (CAMP) Cyclic Adenosine Monophosphate. Cyclic Adenosine Monophosphate. There is no effect on alpha or beta-receptors.There is no effect on alpha or beta-receptors. Increase contractile force and velocity of relaxation of Increase contractile force and velocity of relaxation of

cardiac muscle.cardiac muscle. Increasing cardiac output without increasing myocardial Increasing cardiac output without increasing myocardial oxygen consumption. oxygen consumption. They cause vasodilation and a decrease in SVR (systemic They cause vasodilation and a decrease in SVR (systemic

vascular resistance) and PVR (Pulmonary vascular vascular resistance) and PVR (Pulmonary vascular resistance & in afterload (resistance to ventricular resistance & in afterload (resistance to ventricular

ejection)ejection)

AMRINONE (INOCOR)AMRINONE (INOCOR)

Has a hemodynamic effect similar to Dobutamine. Has a hemodynamic effect similar to Dobutamine. Increase cardiac output and decrease pulmonary Increase cardiac output and decrease pulmonary

vascular resistance. vascular resistance. It should be used with caution in patients with It should be used with caution in patients with

ischemic heart disease because it can exacerbate ischemic heart disease because it can exacerbate ischemia.ischemia.

It should be considered for use in patients with It should be considered for use in patients with severe congestive heart disease, which is no severe congestive heart disease, which is no longer responsive to other inotropes, diuretics, longer responsive to other inotropes, diuretics, and vasodilators. and vasodilators.

It is also used after aorto-coronary bypass It is also used after aorto-coronary bypass surgery.surgery.

It is recommended that the lowest dose that It is recommended that the lowest dose that produce the desired hemodynamic effect to be produce the desired hemodynamic effect to be used.used.  

LOADING DOSE:LOADING DOSE: 0.5 TO 0.75 mg/kg given over 2-3 min. IV0.5 TO 0.75 mg/kg given over 2-3 min. IV DO NOT EXCEED 1 mg/kg.DO NOT EXCEED 1 mg/kg.

    Maintenance dose: -Maintenance dose: - 5 to 10 mcg/kg/min5 to 10 mcg/kg/min

Maximum dose:-Maximum dose:- 10mg/kg/24hours.10mg/kg/24hours.  Doses higher than 15 mcg/kg/minute can Doses higher than 15 mcg/kg/minute can

produce tachycardiaproduce tachycardia  

NEVER DILUTE WITH DEXTROSENEVER DILUTE WITH DEXTROSE! ---Chemical ! ---Chemical reaction occursreaction occurs

Syringe pump: Syringe pump: Use Straight SolutionUse Straight SolutionConcentration 5 mg/ccConcentration 5 mg/cc

Adverse reaction: -Adverse reaction: -Thrombocytopenia occurs in 10% of all Thrombocytopenia occurs in 10% of all

patients seen 48 – 72 hours after patients seen 48 – 72 hours after infusion and resolves when drug is infusion and resolves when drug is discontinued.discontinued.

Gastrointestinal upsetGastrointestinal upsetMyalgiaMyalgiaFeverFeverHepatic dysfunctionHepatic dysfunctionVentricular irritabilityVentricular irritability

Nursing implication: -Nursing implication: -Monitor for arrhythmias, hypotension, Monitor for arrhythmias, hypotension,

thrombocytopenia & hepatotoxicity.thrombocytopenia & hepatotoxicity.

Monitor cardiac output, pulmonary artery pressure Monitor cardiac output, pulmonary artery pressure and heart rate.and heart rate.

Effects last for 2 hours after drip is discontinued.Effects last for 2 hours after drip is discontinued.

The loading dose may be given over 2 to 5 minutes, The loading dose may be given over 2 to 5 minutes, but to prevent Hypotension it is recommended the but to prevent Hypotension it is recommended the loading dose be given over 10 to 15 minutes.loading dose be given over 10 to 15 minutes.

MILRINONE (Primacor)MILRINONE (Primacor)  Milrinone is about 10 fold more potent Milrinone is about 10 fold more potent

than Amrinone. than Amrinone. A positive inotropic agent that increases A positive inotropic agent that increases

cardiac output and decreases systemic cardiac output and decreases systemic vascular resistance.vascular resistance.

Because of its vasodilating effect, Because of its vasodilating effect, Milrinone is not generally associated Milrinone is not generally associated with an increase in myocardial oxygen with an increase in myocardial oxygen demand.demand.

Milrinone can be diluted in dextrose or Milrinone can be diluted in dextrose or saline solution.saline solution.

LOADING DOSE:-LOADING DOSE:- 50 mcg/kg given IV over 10 minutes50 mcg/kg given IV over 10 minutes  MAINTENANCE DOSE:-MAINTENANCE DOSE:- 0.375 to 0.75 mcg/kg/minute0.375 to 0.75 mcg/kg/minute

Warning; -Warning; - DOSES TO HIGH CAN CAUSE DOSES TO HIGH CAN CAUSE

HYPOTENSION AND TACHYCARDIA.HYPOTENSION AND TACHYCARDIA.

MILRINONE IS INCOMPATIBLE MILRINONE IS INCOMPATIBLE WITH LASIX!WITH LASIX!

  ADVERSE EFFECTS:ADVERSE EFFECTS:Supraventricular tachycardiaSupraventricular tachycardiaVentricular arrhythmiasVentricular arrhythmiasVentricular ectopyVentricular ectopyIncreased ventricular rate in atrial Increased ventricular rate in atrial

fibrillation/flutterfibrillation/flutterHeadacheHeadacheHypokalemiaHypokalemiaTremorsTremorsThrombocytopeniaThrombocytopenia

EASY FORMULAS FOR DRUG CALCULATIONS FOR INFUSION EASY FORMULAS FOR DRUG CALCULATIONS FOR INFUSION PUMPSPUMPS

TO DETERMINE DESIRED RATE:-TO DETERMINE DESIRED RATE:-

  (Remember 1 mg = 1000 mcg)(Remember 1 mg = 1000 mcg)  

(Desired mcg) X kg. X 60 ÷ mcg/cc (in solution)(Desired mcg) X kg. X 60 ÷ mcg/cc (in solution)  Example:- Give Dopamine 5 mcg/kg/min to a patient who Example:- Give Dopamine 5 mcg/kg/min to a patient who

weights 65 kg.weights 65 kg.  

5 X 65 X 60 ÷ (800 mg in 500 cc)5 X 65 X 60 ÷ (800 mg in 500 cc)  (5 mcg) X (65 kg) X 60 ÷ (800 mg ÷ 500 cc = 1.6 mg. (5 mcg) X (65 kg) X 60 ÷ (800 mg ÷ 500 cc = 1.6 mg. X 1000) X 1000)

= 1600 mcg= 1600 mcg19500 ÷ 1600 = 12.18 cc19500 ÷ 1600 = 12.18 cc

  Example: Give Dopamine 2.5 mcg/kg/min to a patient who Example: Give Dopamine 2.5 mcg/kg/min to a patient who

weight 55 KG.weight 55 KG.  

2.5  X 55 X 60 ÷ 16002.5  X 55 X 60 ÷ 1600 (2.5 mcg) X (55 kg) X 60 ÷ 1600 = 5.15 cc(2.5 mcg) X (55 kg) X 60 ÷ 1600 = 5.15 cc

TO DETERMINE MCG/KG/CC INFUSING:TO DETERMINE MCG/KG/CC INFUSING:

Example:Example: You have a patient that weighs 85 kg who You have a patient that weighs 85 kg who has a dopamine drip infusion at 8cc per hour and you has a dopamine drip infusion at 8cc per hour and you want to determine how many mcg/kg/min the patient want to determine how many mcg/kg/min the patient is receiving. The dopamine is mixed at 1600 mcg per is receiving. The dopamine is mixed at 1600 mcg per cc.cc.

  MCG/CC X RATE ÷ 60 ÷ KGMCG/CC X RATE ÷ 60 ÷ KG

  1600 X 8 ÷ 60 ÷ 85 = 2.5 mcg/kg/minute1600 X 8 ÷ 60 ÷ 85 = 2.5 mcg/kg/minute

  ExampleExample: You have a patient that weighs 102 kg who : You have a patient that weighs 102 kg who

has a Dobutamine drip infusing at 12 cc per hour and has a Dobutamine drip infusing at 12 cc per hour and you want to determine how many mcg/kg/min the you want to determine how many mcg/kg/min the patient is receiving. The Dobutamine is mixed at 500 patient is receiving. The Dobutamine is mixed at 500 mg in 250 cc = 2000 mcg per cc.mg in 250 cc = 2000 mcg per cc.

  (500 mg ÷ 250 = 2 X 1000 = 2000)(500 mg ÷ 250 = 2 X 1000 = 2000)

  2000 X 12 ÷ 60 ÷ 102 = 3.92 mcg/kg/min.2000 X 12 ÷ 60 ÷ 102 = 3.92 mcg/kg/min.

  

CONCLUSIONCONCLUSION

Inotropes are very effective drugs when Inotropes are very effective drugs when administered properly. administered properly.

Patients receiving inotropes should be monitored Patients receiving inotropes should be monitored closely including blood pressure, cardiac closely including blood pressure, cardiac monitoring, intake and output, and laboratory tests monitoring, intake and output, and laboratory tests that have been ordered by the physician.that have been ordered by the physician.

Knowledge of desired effects and side effects is Knowledge of desired effects and side effects is critical to the administration of inotropes. critical to the administration of inotropes.

  

CONCLUSIONCONCLUSIONCont…Cont…

A thorough grasp of the pharmacology of inotropes is crucial to A thorough grasp of the pharmacology of inotropes is crucial to understand the rationale for drug therapy of heart failure.understand the rationale for drug therapy of heart failure.

Inotropes continue to improve through scientific research. Inotropes continue to improve through scientific research. Oral forms of inotropes are now being investigated to manage Oral forms of inotropes are now being investigated to manage

congestive heart failure at home. congestive heart failure at home.

Advanced knowledge by the healthcare workers that administer Advanced knowledge by the healthcare workers that administer inotropes will ensure positive patient outcomes.inotropes will ensure positive patient outcomes.

  

BIBLIOGRAPHYBIBLIOGRAPHY

  ACLS, Emergency Cardiovascular Care Program, ACLS, Emergency Cardiovascular Care Program,

American Heart Association, 1997-1998, pp. 7.3-American Heart Association, 1997-1998, pp. 7.3-7.4, 8.3-8.8.7.4, 8.3-8.8.

Braunwald; Heart Disease, 1998, W. B. Saunders Braunwald; Heart Disease, 1998, W. B. Saunders Company, pp. 9468-9470, 9477-9481, 9492-Company, pp. 9468-9470, 9477-9481, 9492-9502.9502.

Critical Care Nursing-Diagnosis and Critical Care Nursing-Diagnosis and Management, Second Edition. L. Thelan, et al. Management, Second Edition. L. Thelan, et al. Mosby-Year Book, Inc. 1994. pp 346-347Mosby-Year Book, Inc. 1994. pp 346-347

Physician’s Desk Reference, 1997, pp. 1116-Physician’s Desk Reference, 1997, pp. 1116-1118.1118.