This document discusses various inotropes and vasoactive agents used to support hemodynamics. It describes the classification of agents as inotropes, chronotropes, vasopressors, or vasodilators. Key agents covered include dopamine, dobutamine, adrenaline, noradrenaline, milrinone, vasopressin, nitroglycerine, and sodium nitroprusside. For each agent, the document discusses receptor physiology, hemodynamic effects, indications, dosing, side effects, and monitoring considerations. It concludes with describing a vasoactive inotrope score used to quantify cardiovascular support.

1. INOTROPES
&
VASOACTIVE AGENTS
Dr.MANOJ PRABHAKAR
Resident , Dept. of Paediatrics

2. • Catecholamines : Dopamine, Dobutamine,
Adrenaline, Noradrenaline
• Phosphodiesterase Inhibitors : Milrinone,
Amrinone
• Vasopressors : Vasopressin, Phenylephrine
• Vasodilators : Nitroglycerine,Sodium
Nitroprusside
Individual Agents

3. Types of receptor & expected physiologic response
Receptor Physiologic response Agent
Alpha 1 Systemic & pulmonary
arteriolar
vasoconstriction
Adr, NA, Dop
Beta 1 Increased contractility &
heart rate
Adr > Dop, Dobut > NA
Beta 2 Systemic vasodilation,
bronchodilation,
hypokalemia
Adr, Dobut
Dopaminergic Increased renal and
splanchnic blood flow
Dopamine

4. Classification
Agent Physiologic response End result Examples
Inotrope ↑ cardiac contraction ↑ CO, BP
unchanged or ↑
Dop, dobut, milrin,
Adr,
Chronotrope ↑ HR ↑ CO , ↑ HR Isopren, dop, adr,
dobut ( higher dose)
Vasopressor ↑ vascular tone, ↑ SVR&
PVR
↑ BP, CO
unchanged or ↓
Adr,, NA, vasopressin,
dop ( higher dose)
Vasodilator ↓ arterial + venous tone, ↓
SVR & PVR
BP unchanged or
↓, CO ↑
SNP, NTG, milrinone
Inodilator ↑ cardiac contraction,
↓ SVR & PVR
↑ CO , , BP
unchanged or ↑
Milrinone, dobut,
levosimendan
Lusitrope diastolic relaxation of
ventricles
↑ CO ( if diastolic
dysfunction
present)
milrinone

5. Dopamine
• Hemodynamic effects:
Dose dependent
- Low dose : 2-5mcg/kg/min
- Mod dose : 5-10mcg/kg/min
- High dose : >10mcg/kg/min
• Indication :
Fluid refractory septic shock
Cardiogenic shock with moderate hypotension

6. Side effects
• Vasoconstriction
• Arryhthmias
• Extravasation
• Tachyphyllaxis

7. Dobutamine
• Hemodynamic effects:
Improves cardiac output by improving stroke volume &
decreasing afterload with minimal tachycardia.
• Indications :
- Cardiogenic shock with normal BP
- Fluid refractory septic shock with normal BP and
impaired extremity perfusion

8. Side effects
• Increases myocardial oxygen consumption
leading to supply-demand mismatch.
• Tachycardia & arrhythmias.

9. Adrenaline /Epinephrine
• Hemodynamic effects:
0.05 – 0.3 mics/kg/min – inotropy, chronotropy
0.3- 1 mics/kg/min – pressor
• ↑ myocardial O2 consumption can worsen
supply demand mismatch

10. NOTE
• At rates > 0.5, bp can ↑ but CO and organ
perfusion can worsen with a potential for
vulnerable organ ( gut, kidneys) iscemia
and failure. ( Numbers look better but
patients perfusion may be worse)

11. Indication
• Cardiogenic shock with decompensated shock
{ Improves diastolic BP, resulting in better coronary
perfusion & improved myocardial function }
• Myocardial dysfunction after cardiac arrest
• Cold septic shock refractory to fluids &
dobutamine/dopamine.
• Severe shock of any etiology

12. How to start and titrate
• Start infusion @0.1-0.3 mcg/kg/min.
• If BP improves but perfusion worsens add
inodilators
• Doses > 0.6 mics/kg/min are rarely useful as
ensuing organ ischemia may lead to MODS

13. Side effects
• Cvs : ↑ afterload, tachycardia,
subendocardial ischemia & arrythmias
• Metabolic: hyperglycemia, hypokalemia,
↑ lactate
• CNS : Excitability, tremors.
• Blunting beta effect

14. Noradrenaline (NA)
• Hemodynamic effects:
Increases BP by vasoconstriction.
• Indications :
- Vasodilatory shock
- Warm septic shock
- Raised ICP

15. Side effects
• ↑ Afterload { not appropriate in cardiogenic
shock}
• Worsens perfusion leading to multi organ
failure.

16. Vasopressin
• Potent pressor.
• Indication :
- Catecolamine resistant , vasodilatory
septic shock - after maximum NA(0.5-
1mcg/kg/min)
- Central DI

17. PDE inhibitors
• Results in increased cellular concentrations of
cAMP by inhibiting its destruction.
• Inotropy, lusitropy, vasodilatory with no
chronotropy resulting in improved
contractility,decreased preload & afterload.
• Synergestic effects with catecholamines

18. Indication
• Catecholamine refractory cold shock with
normal BP..
• Cardiogenic shock with normal BP.
• Pulmonary hypertension

19. Side effects
• Hypotension
• Toxicity in renal failure
• Long half life
• Thrombocytopenia

20. Nitroglycerin (NTG)
• Hemodynamics : Venodilator
Indications
• Acute pulmonary edema & pulmonary HTN.
• Cardiogenic shock with precarious hemodynamics
Side effects:
• Hypotension & tolerance

21. Sodium Nitroprusside(SNP)
• Produces arterial vasodilation resulting in
preload and afterload.
• Hemodynamics:
↓ SVR, ↓ PVR
Rapid half life of 2 mins

22. Indications :
Severe HTN.
Side effects:
Hypotension
Cyanide toxicity

23. Levosimendan
• Calcium Sensitizer : New class of agent that
increases sensitivity of cardiac myofilament to
calcium .
• Inotropic and vasodilatory properties.
• Most extensively studied in acute heart
failure, but given the potential role for
abnormal calcium handling in sepsis-induced
myocardial depression, its use also has been
proposed in sepsis.

25. Care & Monitoring
• Tailored to desired hemodynamics response
• Cardiorespiratory monitoring in ICU
• Sideeffects if patient is hypovolumic or normal
cardiac function
• Rapid purge
• Freshly prepared solution

26. Vasoactive inotrope score
• Wernovsky et al and modified by
• Skippen and Krahn.
• 1 X dopamine (mics/kg per minute) + 1 X
dobutamine +15 X milrinone + 100 X
epinephrine +100 X norepinephrine +1000
X vasopressin (expressed as U/kg/per
minute).

28. Thankyou