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Physical exam and assessment

Inotropes and vasopressors

The following is a very simplified approach to the choice of inotropes and vasopressors. More information can be found at the Critical Care Drug Manual – London Health Sciences Centre, UWO.

Inotropes

  1. Adrenergic (catecholamine)
    • Dobutamine – beta-agonist (ß1 >ß2). Increases contractility and HR. ß2 effect can sometimes decrease SVR and BP. ß1 effect can cause dysrhythmias. Start at 2.5 mcg/kg/min. Titrate upward by 2.5 mcg/kg/min until adequate cardiac index. Maximum 15 to 20 mcg/kg/min. Notify ICU Fellow or Attending if at 10 mcg/kg/min or higher.
    • Epinephrine -alpha and beta agonist (ß > alpha). Increases HR, CO, and SVR. Generally a second-line inotrope. A subset of patients who do not respond to dobutamine will respond to epinephrine. Potential detrimental effects include significant increases in myocardial oxygen consumption, increased lactic acidosis, arrhythmias. Start at 0.5 to 1.0 mcg/min and increase by these amounts until adequate cardiac index. Notify ICU Fellow or Attending if > 5 mcg/min and each increase of 5 mcg/min above that.
    • Dopamine – stimulates dopaminergic, beta, and alpha receptors in dose-dependent fashion. Inotropic effect (beta-effect) predominates in the 5 to 10 mcg/kg/min range. Notify ICU Fellow or Attending if at 10 mcg/kg/min or higher. There appears to be little benefit over Dobutamine as an inotrope. In low doses ( 2 – 4 mcg/kg/min) it has been purported to have beneficial renal protective effects (“renal-dose dopamine”). While it can increase urine output by several mechanisms, there is little evidence that it improves creatinine clearance or decreases the incidence of acute renal failure.