Commonly used Inotropic & Vasopressor Agents

Commonly used Inotropic & Vasopressor Agents: 

Ref. Braunwald Heart disease 12th Ed.

DRUG	CLINICAL INDICATION	DOSE
CATECHOLAMINES:
Dopamine*	Shock (vasodilatory, cardiogenic)	2 - 20  μg /kg/min (Max-50)
Dobutamine*	Low CO (decompensated HF, cardiogenic shock, sepsis induced cardiac dysfunction)	2 - 20  μg /kg/min (Max-40)
Norepinephrine	Shock (vasodilatory, cardiogenic)	0.01 - 3  μg /kg/min
Epinephrine	Cardiac arrest Anaphylaxis Shock (vasodilatory, cardiogenic)	Infusion: 0.01 - 0.10  μg /kg/min Bolus: 1 mg IV q 3-5 mins (max 0.2 mg/kg) IM: [1:1000] 0.1 -0.5 mg (max 1 mg)
Isoproterenol	Bradyarrhythmias Brugada syndrome	Infusion: 2 - 10 μg /min
Phenylephrine	Hypotension (vagal shock, medication induced, Aortic stenosis, HOCM)	Bolus: 0.1 - 0.5 mg IV q 10 to 15 mins Infusion: 0.4 - 10 μg /kg/min
OTHER AGENTS:
Vasopressin	Shock (vasodilatory, cardiogenic) Cardiac arrest	Bolus: 40 U IV bolus Infusion: 0.01 - 0.1 U/min (Common fixed dose 0.04 u/min)
Levosimendan	Decompensated HF	Loading dose: 12 - 24  μg /kg over 10 mins Infusion: 0.05 - 0.2  μg /kg/min
Phosphodiesterase     inhibitors:
Milrinone	Low CO (decompensated HF, after cardiotomy)	Infusion: 0.375 - 0.75 μg /kg/min  (Dose adjustment needed for renal failure)

* For symptomatic bradycardia unresponsive to atropine or pacing - Use dopamine / dobutamine

Drugs in Acute Heart Failure

DRUGS FOR ACUTE HEART FAILURE: 

REF: Braunwald12th ed.

VASODILATORS:	INITIAL DOSE	EFFECTIVE DOSE RANGE
1.Nitroglycerin	20 μg/min	40 - 400 μg/min
2.Nitroprusside	0.3 μg /kg/min	0.3 - 5 μg /kg/min
3.Nesiritide	2 μg /kg bolus	0.010 - 0.030 μg /kg/min
IONOTROPES:
1.Dopamine	4 - 5 μg /kg/min	5 - 20 μg /kg/min
2.Dobutamine	1 - 2 μg /kg/min	2 - 20 μg /kg/min
3.Norepinephrine		0.2 - 1 μg /kg/min
4.Epinephrine		0.05 - 0.5 μg /kg/min
5.Milrinone	25-75 μg /kg bolus over 10 – 20 mins, f/b infusion	0.10 - 0.75 μg /kg/min
6.Levosimendan	12-24 μg /kg bolus over 10 min, f/b infusion	0.5 - 2 μg /kg/min
7.Digoxin	0.5 mg IV	0.25 mg IV or Oral 12 hours after initial dose and continue if needed
DIURETICS:
SEVERITY OF VOLUME OVERLOAD	DIURETIC	DOSE (mg)
1.Moderate	Furosemide	20-40 mg IV or up to 2.5 times oral dose (outpatient dose) IV
	Bumetanide	0.5 - 1 mg
	Torsemide	10 - 20 mg
2.severe	Furosemide	40-160 mg or up to 2.5 times Oral dose 5-40 mg/hr infusion
	Bumetanide	0.5-2 mg/hr (Max 2-4 mg/hr)
	Torsemide	5-20 mg/hr
	Ultrafiltration	200-500 mL/hr
3.Refractory to Loop diuretics	Add HCTZ	25-50 mg twice daily
	Metolazone	2.5-10mg once daily
	Chlorothiazide	250-500 mg IV 500-1000 mg PO
	Spironolactone	25-50 mg once daily
4.If alkalosis present	Acetazolamide	0.5 mg IV
5.Refractory to Loop & Thiazides	Add Dopamine (1-4 μg/kg/min - renal vasodilation) Dobutamine or Milrinone
	Ultrafiltration or Hemodialysis (if associated renal failure present)

INSULIN DOSAGE - PRACTICAL POINTS

CALCULATING AND ADJUSTING INSULIN DOSAGE:

TYPE 1 DIABETES MELLITUS: 0.3 - 0.7 Units/kg/day of insulin Ref. Harrison 21st Ed.

                                                         0.4 - 1.0 Units/kg/day Ref. ADA guidelines.

Higher amounts are required during puberty, pregnancy, medical illness.

Lower amounts are required in renal failure.

 Start at 0.5 U/kg/day (TDI - Total Daily Insulin)

                       ↓

50% of TDI as Basal     &    50 % of TDI as Prandial/Bolus/Nutritional Insulin

                       ↓

To this insulin Add Supplemental / correcting insulin based on Pre-prandial glucose

Correction factor/Insulin sensitive factor:  

         a) Body weight(kg) x (Actual Blood glucose - Desired Blood Glucose) ÷ 1500 = Units to be added /subtracted

(OR) b) 1 U of Insulin for every 30-60 mg/dl 

(OR) c) 1500 / TDI for Regular Insulin e.g., 1500/30U = 50U i.e., 1 U will reduce 50 mg/dl. 

             1800 / TDI for Rapid acting Insulin (Lispro, Aspart, Glulisine)

(OR) d) Insulin -to- carbohydrate ratio: 

              Lunch & Supper: 1 Unit Insulin / 10-15 g of Carbohydrate (CHO) 

              Breakfast: 1.5 U / 10 g of CHO Since growth hormone & cortisol levels are high at morning.

              (Must be determined for each individual). Ref. ADA.

Example:

 70 kg person requires TDI 

                  ↓

 0.5 x 60 = 30 U / day (TDI)

                  ↓

Basal (50%) 15 U + Prandial (50%) 15 U [e.g., R5 N5 - R5 - R5 N5]

                  ↓

If pre-lunch CBG is 250 mg/dl and Desired CBG is 180 mg/dl

correction factor = 60 x (250-180) ÷ 1500 ≈ 3 U i.e., R8 to be given before lunch

similarly, Morning and Night doses to be adjusted according to above formula

or Simply Titrate 2U every 3 days till target CBG goals achieved.

WHICH INSULIN TO BE ADJUSTED: (Ref. ADA)

If this glucose levels are out of target                  Adjust this insulin component

1.Post Breakfast / Pre-Lunch                   →          Pre-Breakfast Rapid/short Insulin

2.Post Lunch / Pre supper                        →          Pre-Lunch Rapid/short and/or Morning NPH                                                                                                                       

3.Mid Afternoon                                      →          Morning NPH or Long-acting insulin

4.Post supper / Bedtime                          →           Pre supper Rapid/short Insulin

5.Early Morning (FBS)                           →           Evening NPH or Long-acting insulin

TIMING OF INSULIN INJECTION:

Short acting insulin analogues -- Just before (< 10 Min) meals

Regular Insulin analogues -- 30-45 mins before meals

BLOOD GLUCOSE TARGETS:  

HBA1C: < 7.0 %

Fasting BG: 80 - 130 mg/dl

Post Prandial BG: < 180 mg/dl

NOTE: References: Harrison 21st Ed., Google scholars. 

The above mentioned are for educational purposes and not for patients use.

KINDLY E-MAIL IF ANY CORRECTIONS IN THE ABOVE