CVS常用药物概论

按一下以編輯標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,CVS 常用藥物概論,Yeh Yu Chang,94.06.04.,分類,Inotropes: 強心,Chronotropic: 增快心律,Pressors: 升壓,Vasodilator: 降壓,Antiarrhytmic agents:抗心律不整,常用藥物,Bosmine (Epinephrine),Levophed (Norepinephrine),Dopamine,Dobutamine,Primacor (Milrinone),Isuprel,NTG,Nitroglyceride,Perdipine,Amiodarone,PGE1,DDAVP,Cardiovascular Anatomy,CONTRACTILITY,HEART,RATE,Rhythm,PRELOAD,AFTERLOAD,L/Min,CARDIAC,OUTPUT,(CI=CO/m,),Catecholamines,Natural,Norepinephrine:,a,b,1,Epinephrine:,a,b,Dopamine: D,a,1,b,1,(also some NE release),Synthetic,Isoproterenol:,b,Dobutamine:,b,1,(and mix of,b,2,stimulation and,a,1,inhibition and stimulation),NE E ISO,Epinephrine,0.1-1 g/kg/min,1mg in 20 ml,5 mg / 100 ml,50 kg 0.167 g/kg/min,Dopamine,1-20 (50) g/kg/min,400 mg in 250 mL,160 mg/ 100 ml,Dobutamine,1-20 (30) g/kg/min,250 mg in 100 ml,Isuprel,0.02-0.15 g/kg/min,0.2 mg in 20 ml,1 mg /100 ml,Levophed,0.04-0.4 g/kg/min,4mg in 50 ml adult,1mg in 50 ml child,Primacor,IV loading 50ug/kg over 10min,Maintenance 0.375-0.75 g/kg/min,10 mg in 10 ml,50 kg 15 ml/h run 10 min then 1 ml/h,NTG,0.1-4,g/kg/min,5 mg in 10 ml,50 mg in 100 ml,Nitroglyceride,0.25-10,g/kg/min,Perdipine,0.5 15 mg/h,1mg/1ml,Amiodarone,Adult,IV 150mg over 10min,then 1mg/min for 6hr,then 0.5mg/min for 18 hr,3 amp in 30 ml,Run 60 ml/h for 10 min,Then 4 ml/h for 6 h,Then 2 ml/h for 18 h,Child,5 mg/kg loading,then 5-15,g/kg/min,1/2 amp in 15 ml,PGE 1,25-250,ng,/kg/min,20 g/powder,or,500g/ml,DDAVP,0.3 g/kg dilute in 50 ml NS over 100 ml/h,4 g/ml,50 kg need 15 g,4 vial in 50 ml run 100 ml/h,80 kg need 24 g,6 vial in 50 ml run 100 ml/h,g/kg/min,160 mg in 100 ml, 50 kg (mg/ml),160*,1000,: mg/ml g/ml,160 *,1000,/,100,: 100ml 1ml,160 *1000/100/,60,: g/h g/min,160/6/,50,= 0.533 g/kg/min,Thanks for your attention! Have a nice weekend!,Thanks for your attention! Have a nice weekend!,Thanks for your attention! Have a nice weekend!,ALPHA-ADRENERGIC MEDICATIONS,Can be divided into:,Alpha,1,-adrenergic effects:,Vascular smooth muscle contraction,Alpha,2,-adrenergic effects:,Vascular smooth muscle relaxation-this is a very mild effect only at low doses of an alpha-adrenergic agent like epinephrine.,BETA-ADRENERGIC MEDICATIONS,Can be divided into:,Beta,1,-adrenergic effects:,Direct cardiac effects,Inotropy (improved cardiac contractility),Chronotropy (increased heart rate),Beta,2,-adrenergic effects:,Vasodilation,Bronchodilation,Epinephrine,1 ,contractility and H.R C.O. and myocardial oxygen demand.,1 ,splanchnic and renal blood flow butcoronary and cerebral perfusion pressure, SBP,2 ,vasodilation in skeletal muscle may lower diastolic pressure also relaxes bronchial smooth muscle,Dopamine vs Dobutamine,Selecting inotropic and vasopressor agents for specific hemodynamic disturbances in children,Hemodynamic pattern,Normal,Deceased,Elevated,Blood pressure or SVR,Myocardial dysfunction,Dobutamine or dopamine,or amrinone,Epinephrine or dopamine,(or dobutamine plus,norepinephrine),Dobutamine,plus,nitroprusside,CHF,Dobutamine,Primacor,Dopamine,Dobutamine,plus,nitroprusside,Bradycardia,None,Isoproterenol,None,Dobutamine Indications,Consider for pump problems (CHF) with systolic blood pressure of 70 to 100 mm Hg and,no,signs of shock,Dobutamine Precautions,Avoid with systolic blood pressure 10% of baseline,Hemodynamic monitoring is recommended for optimal use,Dopamine,Indications,2,nd,drug for symptomatic bradycardia after atropine,Use for hypotension (systolic blood pressure = 70 - 100 mm Hg) with signs and symptoms of shock,Dopamine Precautions,May use in patients with hypovolemia but only after volume replacement,Use with caution in cardiogenic shock with accompanying congestive heart failure,May cause tachyarrhythmias, excessive vasoconstriction,Taper slowly.,Do not mix with sodium bicarbonate,Dopamine Continuous Infusions,Titrate to patient response:,Low Dose,1 to 5 g/kg per minute (“renal doses),Moderate Dose,5 to 10 g/kg per minute (“cardiac doses”),High Dose,10 to 20 g/kg per minute (“pressor doses”),Epinephrine Indications,Cardiac arrest:,VF, pulseless VT, asystole, PEA,Symptomatic bradycardia:,After atropine, dopamine and TCP,Severe hypotension,Anaphylaxis:,Combine with large fluid volumes, corticosteroids, antihistamines,Epinephrine,Precautions,Raising BP and increasing HR may cause myocardial ischemia, angina,High doses do not improve survival or neurologic outcome and may contribute to postresuscitation myocardial dysfunction,Higher doses,may,be required to treat poison/drug-induced shock,Epinephrine in Cardiac Arrest,IV Dose:,1 mg (10 mL of 1:10 000 solution) administered every 3 to 5 minutes during resuscitation,Follow each dose with 20 mL IV flush.,ETT:,2 to 2.5 mg (1:1000) diluted in 10 mL normal saline.,Isoproterenol Indications,Use cautiously as,temporizing,measure if,external pacer is not available,for treatment of symptomatic bradycardia,Refractory torsades unresponsive to MgSO,4,Temporary,control of bradycardia in heart transplant patients,Poisoning from -adrenergic blockers,Isoproterenol Precautions,Do not use for treatment of cardiac arrest,Increases myocardial oxygen requirements,Do not give with epinephrine; can cause VF/VT,Do not administer with poison/drug induced shock (exception: -blocker poisoning),Higher doses are Class III (harmful) except for -adrenergic blocker poisoning,Isoproterenol IV Infusion,Infuse at 2 to 10 g/min,Titrate to adequate heart rate,In torsades, titrate to increase heart rate until VT is suppressed,Lidocaine Indications,Cardiac arrest from VF/VT,Stable VT, wide-complex tachycardias of uncertain type, wide-complex PSVT (Class Indeterminate),Lidocaine Precautions,Prophylactic,use in AMI patients is,not,recommended,Reduce maintenance dose (not loading dose) in presence of impaired liver function or left ventricular dysfunction,Discontinue infusion immediately if signs of toxicity develop,Lidocaine inCardiac Arrest From VF/VT,Initial dose: 1 to 1.5 mg/kg IV,For refractory VF may give additional 0.5 to 0.75 mg/kg IV push, repeat in 5 to 10 minutes; maximum total dose: 3 mg/kg.,ETT: 2 to 4 mg/kg.,Lidocaine,Perfusing Arrhythmia,For stable VT, wide-complex tachycardia of uncertain type, significant ectopy: 1 to 1.5 mg/kg IVP,Repeat 0.5 to 0.75 mg/kg every 5 to 10 minutes,Maximum total dose: 3 mg/kg.,Maintenance Infusion,2 to 4 mg/min,Magnesium Sulfate Indications,Cardiac arrest only if torsades de pointes or suspected hypomagnesemia is present,Refractory VF (after lidocaine),Torsades de pointes with a pulse,Life-threatening ventricular arrhythmias due to digitalis toxicity,Magnesium Sulfate Precautions,Occasional fall in blood pressure with rapid administration.,Use with caution if renal failure is present.,Magnesium Sulfate Administration,Cardiac Arrest (for hypomagnesemia or TdP),1 to 2 g (2 to 4 mL of a 50% solution) diluted in 10 mL of D5W IVP,Torsades de Pointes (not in cardiac arrest),Loading dose of 1 to 2 g mixed in 50 to 100 mL of D5W, over 5 to 60 minutes IV,Follow with 0.5 to 1 g/h IV (titrate dose to control the torsades),Nitroglycerin Indications,Initial antianginal for suspected ischemic pain,For initial 24 to 48 hours in patients with,AMI and CHF, large anterior wall infarction, persistent or recurrent ischemia, or hypertension,Continued use (beyond 48 hours) for patients with recurrent angina or persistent pulmonary congestion,Hypertensive urgency with ACS,NitroglycerinPrecautions/Contraindications,Limit normotensive BP drop to 10%,Limit hypertensive BP drop to 30%,Avoid BP drop below 90 mm Hg,Do not mix with other drugs,Sit or lie pt down when receiving med,Do not shake aerosol spray (affects metered dose),Contraindications,Hypotension,Severe bradycardia or severe tachycardia,RV infarction,Viagra within 24 hours,Nitroglycerin Administration,IV Bolus/Infusion,IV bolus: 12.5 to 25 g,Infuse at 10 to 20 g/min,Route of choice for emergencies,Titrate to effect,Sublingual Route,1 tablet (0.3 to 0.4 mg); repeat every 5 minutes.,Aerosol Spray,Spray for 0.5 to 1 second at 5-minute intervals (provides 0.4 mg per dose).,Nitroprusside Indications,Hypertensive crisis.,To reduce afterload in heart failure and acute pulmonary edema,To reduce afterload in acute mitral or aortic valve regurgitation,Nitroprusside Precautions,Light-sensitive; therefore, wrap drug reservoir in aluminum foil,May cause hypotension, thiocyanate toxicity, and CO,2,retention.,May reverse hypoxic pulmonary vasoconstriction in patients with pulmonary disease, exacerbating intrapulmonary shunting, resulting in hypoxemia,Other side effects include headaches, nausea, vomiting, and abdominal cramps,Nitroprusside IV Infusion,Begin at 0.1 g/kg per minute and titrate upward every 3 to 5 minutes to desired effect (up to 5 g/kg per minute).,Use with an infusion pump,Action occurs within 1 to 2 minutes,Norepinephrine Indications,For severe cardiogenic shock and hemodynamically significant hypotension (BP 2.0 = mostly alpha,1,increase SVR, and may decrease CO by increasing afterload,EPINEPHRINE,Side effects include:,Anxiety, tremors,palpitations,Tachycardia and tachyarrhythmias,Increased myocardial oxygen requirements and potential to cause ischemia,Decreased splanchnic and hepatic circulation (elevation of AST and ALT),Anti-Insulin effects: lactic acidosis, hyperglycemia,NOREPINEPHRINE,Employed primarily for its alpha agonist effect - increases SVR (and B.P.) without significantly increasing C.O.,Used in cases of low SVR and hypotension such as profound “warm shock” with a normal or high C.O. state,Infusion rates titrated between 0.05 to 1 mcg/kg/min,NOREPINEPHRINE,In general, norepinephrine differs from epinephrine in that at doses used in clinical practice, the vasoconstriction outweighs any increase in cardiac output.,i.e. norepinephrine usually increases blood pressure and SVR, often without increasing cardiac output.,NOREPINEPHRINE,Side Effects:,Similar to those of Epinephrine,Can compromise perfusion in extremities and may need to be combined with a vasodilator e.g. Dobutamine or Nipride,More profound effect on sphlancnic circulation and myocardial oxygen consumption,DOPAMINE,Intermediate product in the enzymatic pathway leading to the production of norepinephrine; thus, it indirectly acts by releasing norepinephrine.,Directly has alpha, beta and dopaminergic actions which are dose-dependent.,Indications are based on the adrenergic actions desired.,DOPAMINE,Improve renal perfusion 2-5 mcg/kg/min,Improve C.O. in mild to moderate Cardiogenic or Distributive Shock 5-10mcg/kg/min,Post-resuscitation stabilization in patients with hypotension (in conjuction with fluid therapy) 10-20mcg/kg/min,DOBUTAMINE,Synthetic catecholamine with inotropic effect (increases stroke volume) and peripheral vasodilation (decreases afterload),Positive chronotropic effect (increases HR),Some lusotropic effect,Overall, improves Cardiac Output by above beta-agonist acitivity,DOBUTAMINE,Major metabolite is 3-,O,-methyldobutamine, a potent inhibitor of alpha-adrenoceptors.,Therefore, vasodilation is possible secondary to this metabolite.,Usual starting infusion rate is 5 mcg/kg/min, with the dose being titrated to effect up to 20 mcg/kg/min.,DOBUTAMINE,Used in low C.O. states and CHF e.g. myocarditis, cardiomyopathy, myocardial infarction,If BP adequate, can be combined with afterload reducer (Nipride or ACE inhibitor),In combination with Epi/Norepi in profound shock states to improve Cardiac Output and provide some peripheral vasodilatation,MILRINONE/AMRINONE,Belong to new class of agents “Bipyridines”,Non-receptor mediated activity based on selective inhibition of Phosphodiesterase Type III enzyme resulting in cAMP accumulation in myocardium,cAMP increases force of contraction and rate and extent of relaxation of myocardium,Inotropic, vasodilator and lusotropic effect,AMRINONE,First generation agent - limited use now,Long half-life (4.4 hours) with potential for prolonged hypotension after loading dose,Associated with thrombocytopenia,Dosage: Load with 0.75 mg/kg with infusion rate of 5-10 mcg/kg/min,Milrinone is preferred drug from this group,MILRINONE,Increases CO by improving contractility, decreased SVR, PVR (?), lusotropic effect; decreased preload due to vasodilatation,Unique in beneficial effects on RV function,Half-life is 1-2 hours,Load with 50 mcg/kg over 30 mins followed by 0.3 to 0.75 mcg/kg/min,No increase in myocardial O2 requirement,VASODILATORS,Classified by site of action,Venodilators: reduce preload - Nitroglycerin,Arteriolar dilators: reduce afterload Minoxidil and Hydralazine,Combined: act on both arterial and venous beds and reduce both pre- and afterload Sodium Nitroprusside (Nipride),NITROPRUSSIDE,Vasodilator that acts directly on arterial and venous vascular smooth muscle.,Indicated in hypertension and low cardiac output states with increased SVR.,Also used in post-operative cardiac surgery to decrease afterload on an injured heart.,Action is immediate; half-life is short; titratable action.,NITROPRUSSIDE,Toxicity is with cyanide, one of the metabolites of the breakdown of nipride.,Severe, unexplained metabolic acidosis might suggest cyanide toxicity.,Dose starts at 0.5 mcg/kg/min and titrate to 5 mcg/kg/min to desired effect. May go higher (up to 10 mcg/kg/min) for short periods of time.,NITROGLYCERIN,Direct vasodilator as well, but the major effect is as a venodilator with lesser effect on arterioles.,Not as effective as nitroprusside in lowering blood pressure.,Another potential benefit is relaxation of the coronary arteries, thus improving myocardial regional blood flow and myocardial oxygen demand.,NITROGLYCERIN,Used to improve myocardial perfusion following cardiac surgery,Dose ranges from 0.5 to 8 mcg/kg/min. Typical dose is 2 mcg/kg/min for 24 to 48 hours post-operatively,Methemoglobinemia is potential side effect,ISOPROTERENOL,Synthetic catecholamine,Non-specific beta agonist with minimal alpha-adrenergic effects.,Causes inotropy, chronotropy, and systemic and pulmonary vasodilatation.,Indications: bradycardia, decreased cardiac output, bronchospasm (bronchodilator).,No longer available in some markets,ISOPROTERENOL,Occasionally used to maintain heart rate following heart transplantation.,Dose starts at 0.01 mcg/kg/min and is increased to 1.0 mcg/kg/min for desired effect.,INHALED NITRIC OXIDE,Selective Pulmonary vasodilator,Dilates only pulmonary capillaries to alveoli participating in gas exchange,Decreases intrapulmonary shunt and improves V/Q matching,Rapidly inactivated by Hgb in pulm. cap. so no systemic side effects (eg hypotension),INHALED NITRIC OXIDE,Potential for use in ARDS and Pulmonary Hypertension,Currently only approved for use in neonatal Pulmonary Hypertension,Expensive,Special monitoring equipment required,Dose: Concentration of 0.5-60 ppm in inhaled gas,Additional considerations,Mechanical ventilation and oxygen therapy (to conserve CO),Analgesia, anxiolysis and sedation,Electrolyte homeostasis esp Ca and Mg,Nutrition - avoid hypoglycemia,Anemia is an “unconstitutional surcharge”,Last but not the least: Maintain appropriate intravascular volume,Selecting inotropic and vasopressor agents for specific hemodynamic disturbances in children,Hemodynamic pattern,Normal,Deceased,Elevated,Blood pressure or SVR,Septic Shock,Stroke index High,Stroke Index low to N,None or dopamine,Dobutamine or dopamine,Norepinephrine,Dopamine or epinephrine,(or dobutamine plus,norephinephrine),None,Dobutamine,plus,nitroprusside,Cardiogenic shock,Dobutamine or amrinone,or dopamine,Epinephrine or dopamine,-,Myocardial dysfunction,Dobutamine or dopamine,or amrinone,Epinephrine or dopamine,(or dobutamine plus,norepinephrine),Dobutamine,plus,nitroprusside,CHF,Dobutamine or dopamine,or amrinone,-,Dobutamine,plus,nitroprusside,Bradycardia,None,Isoproterenol,None,DRIP FORMULA:,6 X WT. IN KG X MCG/KG/MIN,=,mg in 100 ml of D5W/NS,ML/HR,Also another way to calculate is:,ISOPROTERENOL,EPINEPHRINE,NOREPRINEPHRINE,0.6 X BODY WT. IN KG = _ MG IN 100ML,1 ML/HR WILL DELIVER 0.1 MCG/KG/MIN,DOPAMINE,DOBUTAMINE,AMRINONE,NITROPRUSSIDE,6 X BODY WT. IN KG = _ MG IN 100ML,1 ML/HR WILL DELIVER 1 MCG/KG/MIN,分類,Inotropes: agents that improve myocardial contractility and enhance stroke volume,Pressors: agents that increase systemic vascular resistance and increase blood pressure,Chronotropic: Increase heart rate,improve relaxation during diastole