Today, we have a new CV-EMCrit episode: Inotropes Part I with Editor of CV-EMCrit, Trina Augustin.
What Heart Rate to Shoot For?
90-110 in most patients
may go higher if compensating for RHF or extremely low EF
The Inotropes
Dobutamine, the ChronoInotrope
Hits B1, B2 and at higher doses, alpha
Not as much vasodilation as milrinone, but a lot of chronotropy and the possibility of arrhythmia induction
Our Dose Recs
1-5 mcg/kg/min (can go up to 10, but you start risking excessive chronotropy)
Milrinone, the InoDilator
Phosphodiesterase-3 (PDE-3) inhibitor that increases cAMP levels in cardiac myocytes by inhibiting cAMP breakdown by the PDE-3 enzyme leading to increased availability of Ca
Inotropy, lusitropy, but not as much chronotropy. Also comes with vasodilation (arterial, venous, and pulmonary arterial)
Our Dose Recs
0.125 – 0.25 mcg/kg/min (max out at 0.37 mcg/kg/min)
45 minutes to really see clinical effects
DO NOT GIVE THE BOLUS
titrate every 45-60 minutes
2.5 hr clinical half life, but at least doubled with renal failure and in a pt on RRT can be 20 hours
can consider in a patient who is strongly beta-blocked
Inotropic Epinephrine, Dual-faced: the pure Inotrope/Inopressor
Dose range for intrope use
0.01-0.08 mcg/kg/min (for a 70 kg pt, this is 1-5 mcg/min)
Hits B1, B2, and at higher doses, Alpha
Digoxin, Original-G
Trina uses this in AF with RVR in patients with reduced EF
30-45 min before you see clinical effects after a bolus
Delayed clearance with renal dysfunction
125-250 mcg bolus, may repeat x 1, two hours after 1st dose
after those 2 boluses, you really need levels
Levosimendan, New Toy?
A calcium sensitizer that we do not discuss as neither of us have access to the drug
Calcium, “God’s” Inotrope
we discuss this in part 2
Dopamine, Fool’s Inotrope
Just don’t do it, just don’t…
Studies Mentioned…
DOREMI Study
Dobutamine vs. milrinone as inotropes in cardiogenic shock [10.1056/NEJMoa2026845]
CAT STUDY
Epi vs. Norepi in ICU Pts [10.1007/s00134-008-1219-0]
Optima CC
Epi vs. Norepi in Cardiogenic Shock post-MI [10.1016/j.jacc.2018.04.051]
Dobutamine increases heart rate more than epinephrine in patients recovering from aortocoronary bypass surgery
Dobutamine vs. epi (study uses ng but when you convert 0.01-0.03 mcg/kg/min) [10.1016/1053-0770(92)90095-O]
Additional New Information
More on EMCrit
You Need an EMCrit Membership to see this content. Login here if you already have one.
Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
