1. This document discusses various inotropes and vasopressors used to treat shock states including dobutamine, dopamine, epinephrine, and norepinephrine. 2. It provides guidelines on administering these drugs including desired dose ranges, how to calculate infusion rates, and examples of calculating dobutamine infusion rates. 3. The document also matches different shock states, such as septic shock, cardiogenic shock, and hemorrhagic shock, with recommended first-tier and second-tier drug treatments.

1. 1. Inotrope: increases cardiac contractility => support the failing
heart
2. Vasopressor: induces vasoconstriction elevation of mean
arterial pressure => support the failing peripheral vasculature
3. To protect brain, kidney, and other organs
4. Goal: BP max > 90 mmHg, BP medium > 70 mmHg, HR =>
follow up by BP and urine
5. Enough fluid
6. Drive the heart too fast resulting in decreased filling time and
decreased stroke volume. Beside vasoconstriction of splachnic
circulation and coronary arteries

3. Reduced in septic shock
Right Ventricular
End-Diastolic Volume
Right Ventricular End-
Systolic Volume

4. Fluid test: CVP, NS or ringer lactat, no OAP –
hepatomegaly – neck vein distention
Volume: 500 (CVP < 5), 200 (CVP = 5-10), 100 (CVP = 10-15),
50 (CVP > 15)/15 min
Increased CVP
2-5
Wait 10 mins
< 2 > 5
< 2 > 2
Inotropes if BP max
< 90 mmHg
1. CVP or IVC Echo
2. CVP = 10 – 12 mmHg,
clinical more fluid but BP
not increasing

5. Drug Contractility Heart rate Vasoconstrition Cardiac
Output
Dopamin ++ + Depend on
dosage
+
Adrenalin +++ ++ Depend on
dosage
+
Dobutamin ++ + 0 ++
Noradrenali
n
++ No or reduce +++ ++

6. Dobutamine:
- Beta 1
- Cardiogenic shock => septic shock
- 5-15 mcg/kg/min SE IV, reduce effect by time =>
increased dosage.
Dopamine:
- 2-5 mcg/kg/min renal flow => diuretic
- 5-10 mcg/kg/min => Beta 1
- 10-20 mcg/kg/min => alpha, easy induce arrhythmias =>
change to norepinephrin

7. Epinephrine (adrenaline) => severe situation
- 0.1 mcg/kg/min => beta 1
- 0.1-0.5 mcg/kg/min => alpha, beta 1, beta 2
- 0.5-1 mcg/kg/min => alpha
- Cardiogenic shock, septic shock, CPR
- Central venous
- Can administrated IM
Nor epinephrine (nor adrenaline)
- Alpha
- Septic shock
- Effect on organs
- Should use central venous, make sure drug in venous
caused tissue necrosis
- 2-16 mcg/kg/min, SE IV. Peripheral and organ
vasoconstriction.

8. - BP stable (good diuretic, stable clinical, BP max > 90 mmHg,
HR) => reduce dosage 0.1 ml per 4 hr to low dosage => stop
- Add digitalis before you want to reduce dosage of inotropes
and vasopressor
- Never let your nurses to use inotrope’s vein for another IV drug
TO DETERMINE DESIRED RATE
1. Remember 1 mg = 1000 mcg
2. Inotrope mg X 1000 = Inotrope mcg
3. Inotrope mcg ÷ total diluted cc => mcg/cc
4. (Desired mcg) X kg X 60 ÷ mcg/cc (in solution) => cc/hr
Example: Dobutamin 250 mg diluted in 50 cc syringe, given
dosage 5 mcg/kg/min for patient whose weight = 50 kg
1. 250 mg x 1000 = 250,000 mcg
2. 250,000 ÷ 50 cc = 5,000 mcg/cc
3. 5 x 50 x 60 ÷ 5,000 = 3 cc/hr

9. Vasoactive drugs for shock states
Shock state First-tier agents Second-tier agents
Anaphylactic shock Epinephrine, 1 mL of 1:10,000
solution (100 mg),can be given
as a slow IV push, then as a
0.02 mcg/kg/min infusion (5–15
mcg/min
Norepinephrine infused at 0.1–1
mcg/kg/min (0.5–30 mcg/min)
Cardiogenic shock, left
ventricular
SBP < 70, norepinephrine
infused at 0.1–1 mcg/kg/min
(0.5–30 mcg/min)
SBP 70–90, dopamine infused
at 15 mcg/kg/min
SBP > 90, dobutamine infused
at 2–20 mcg/kg/min
Amrinone, 0.75 mcg/kg loading
dose, then 5–10 mcg/kg/min (not
recommended post-MI)
Milrinone, 50 mcg/kg loading
dose, then 5–10 mcg/kg/min (not
recommended post-MI)
Cardiogenic shock,
pulmonary
embolism
Dobutamine infused at 5
mcg/kg/min
Norepinephrine infused at 0.1–1
mcg/kg/min
Phenylephrine infused at 10–20
mcg/kg/min
Hemorrhagic shock Volume resuscitation Dopamine infused at 5–15
mcg/kg/min as a temporizing
adjunct

10. Neurogenic shock Dopamine infused at
5–15 mcg/kg/min
Norpinephrine infused
at 0.1–1 mcg/kg/min
Phenylephrine infused
at 10–20 mcg/kg/min
Septic shock Norepinephrine infused
at 0.1–1 mcg/kg/min
Dobutamine infused at 5
mcg/kg/min
Dopamine infused at 5–
15 mcg/kg/min
Epinephrine infused at
0.02 mcg/kg/min
Toxic drug overdose with
shock
Norepinephrine infused
at 0.1–1 mcg/kg/min
Phenylephrine infused at
10–20 mcg/kg/min
Glucagon given as a 5-
mg IV bolus, then
as a 1–5 mg/h infusion
Calcium salts: calcium
gluconate, 0.6 mL/kg
bolus,
then a 0.6–1.5 mL/kg/h
infusion
Insulin started at 0.1
units/kg/h IV and titrated
to a goal of 1 unit/kg/h