86

CAkDICVASCULAk SS1LM

INC1kCLS













CkI1ICAL CAkL LDUCA1ICN 1LAM knSCL
CAkDICVASCULAk SS1LM INC1kCLS

87
1o undersLand lnoLropes and Lhelr use Lhere musL flrsL be an undersLandlng of Lhe
cardlovascular sysLem

Conduct|on


wave aLrlal depolarlsaLlon
C8S complex depolarlsaLlon of venLrlcles
S1 LranslenL perlod when no elecLronlc currenL can pass Lhrough Lhe myocardlum
1 wave venLrlcles reLurned Lo resLlng phase



8|ood pressure


When Lhe hearL conLracLs blood ls pumped ouL lnLo Lhe body 1he maxlmum pressure measured ln Lhe
arLerles ls called systo||c pressure
When blood fllls Lhe hearL Lhe arLery pressure relaxes and Lhls ls called d|asto||c pressure
We measure blood pressure ln mmPg and monlLor boLh Lhe sysLollc dlasLollc and mean pressure lL ls
deLermlned by card|ac output (flow) and system|c vascu|ar res|stance



llow Lo Lhe Llssues ls cruclally dependenL on mean blood pressure (MA)
88
1hls ls calculaLed by addlng Lhe dlasLollc pressure and 1/3 of Lhe pulse pressure



normal blood pressure
Age SysLollc ulasLollc
8lrLh ( 12 hours 1000g) 39S9 1636
8lrLh ( 12 hours 3kg) S070 2S4S
neonaLe (96 hours) 6090 2060
lnfanL ( 6 monLhs) 8710S S366
1oddler (2years) 9S10S S366
School age 97112 S771
AdolescenL (1S years) 112128 6680
8lood pressure (sysLollc) can be approxlmaLed over Lhe age of 1 year by uslng Lhe formula 80 mmPg + (2
x age ln years) ALS

Lven when Lhe blood pressure falls Lo 7S of normal Lhe Llssues Lry Lo preserve meLabollc funcLlons lL
does Lhls by exLracLlng more oxygen and nuLrlenLs from Lhe blood supply sLlll reachlng Lhem Cnly aL very
low levels of Llssue perfuslon do Lhe Llssues glve up and resorL Lo anaeroblc meLabollsm


cotJloc ootpot
Cardlac ouLpuL ls Lhe amounL of blood pumped by Lhe venLrlcle per mlnuLe lL ls deLermlned by stroke
vo|ume x heart rate

what affects card|ac output?
sysLemlc vascular reslsLance
clrculaLlng volume / cvp
conLracLlllLy
sedaLlon
paln



89
neart rate
PearL raLe varles wlLh age and wlLh acLlvlLy

Age
(years)
PearL raLe (bpm)
1 110160
12 1001S0
2S 9S140
S12 80120
12 60100

An lncrease ln LemperaLure wlll ralse a hearL raLe by 10bpm per degree of lncrease
AglLaLlon dlsLress paln all lncrease Lhe hearL raLe
A varleLy of rhyLhm dlsLurbances may compromlse cardlac ouLpuL
Slnus Lachycardla may glve lnsufflclenL Llme for effecLlve dlasLollc venLrlcular fllllng

ln |nfants sLroke volume ls relaLlvely flxed (1Sml/kg aL blrLh) so cardlac ouLpuL ls rellanL on changes ln
hearL raLe only 1herefore Lhe heart rate ls Lhe maln cause of lncrease or decrease ln cardlac ouLpuL

Stroke vo|ume
SLroke volume ls Lhe amounL of blood pumped ouL of Lhe venLrlcle wlLh each hearLbeaL lL ls deLermlned
by preload cardlac conLracLlllLy afLerload

pre|oad Lhe degree of myocardlal sLreLch aL Lhe end of dlasLole 1haL ls Lhe amounL of blood avallable
for expulslon by Lhe myocardlum
reload ls affecLed by
any change Lo Lhe clrculaLlng blood volume dehydraLlon haemorrhage hypovolaemla
any change ln Lhe blood reLurnlng Lo Lhe hearL vasoconsLrlcLlon / vasodllaLlon
any change Lo venLrlcular fllllng Llme hearL fallure Lamponade change ln hearL raLe

1he greaLer Lhe preload Lhe greaLer Lhe sLroke volume and Lherefore Lhe greaLer Lhe cardlac ouLpuL
Powever lL ls posslble Lo oversLreLch Lhe myocardlum resulLlng ln cardlac compromlse

card|ac contract|||ty Lhe ablllLy of Lhe myocardlum Lo conLracL effecLlvely
May be reduced by myocardlal oedema and decreased venLrlcular compllance LhaL may follow damage
such as ln cardlomyopaLhy or posL cardlac surgery 1he myocardlum can be furLher compromlsed by
volume or pressure overload whlch causes venLrlcular dllaLlon hyperLrophy and lschaemla



after|oad
Lhe reslsLance Lhe venLrlcle musL overcome ln order Lo move blood ln Lhe pulmonary arLery and aorLa
1hls can be dlvlded lnLo system|c vascu|ar res|stance (SVk)
pu|monary vascu|ar res|stance (Vk)
SVk reslsLance Lo blood flow Lhrough Lhe arLerles (lefL venLrlcle)
Vk reslsLance Lo blood flow Lhrough pulmonary arLerles (rlghL venLrlcle)

90
Contractility
HR x SV = CO ~ BP
SVR
Volume
(Preload)


lncreaslng Sv8 lmproves Lhe MA buL may reduce cardlac ouLpuL Lo a level where Llssue perfuslon ls
reduced

Sv8 Sv8



CC

lncreaslng Sv8 may be needed ln a vasodllaLed paLlenL le anaphylaxls or sepsls ln order Lo malnLaln MA
aL a level able Lo perfuse buL lf cardlac ouLpuL ls reduced lncreaslng Sv8 wlll have a negaLlve effecL by
furLher reduclng cardlac ouLpuL whlle lncreaslng 8 (so maklng you feel beLLer)



8emember lncreaslng blood pressure wlLhouL lmprovlng cardlac ouLpuL may lead Lo organ perfuslon
belng compromlsed

1he greaLer Lhe preload Lhe greaLer Lhe sLroke volume and Lherefore Lhe greaLer Lhe cardlac ouLpuL

afLerload CC

preload Sv CC

venLrlcular funcLlon CC
91
Card|ovascu|ar support and |notropes

1he body produces catecho|am|nes whlch are a group of physlologlcally lmporLanL subsLances lncludlng
adrenallne noradrenallne and dopamlne
1hey have dlfferenL roles malnly as neurotransm|tters ln Lhe funcLlonlng of Lhe sympaLheLlc and
cenLral nervous sysLem 1hey occur naLurally wlLhln Lhe body

normally Lhls ls auLomaLlcally conLrolled and can lncrease or decrease accordlng Lo Lhe body's need
ln sLress Lhe producLlon lncreases Lo provlde 'f|ght or f||ght' response see below
1he body's coplng mechanlsm can only compensaLe for so long before Lhe body's equlllbrlum ls
challenged and becomes unable Lo malnLaln normosLasls
lmprovemenL ln cardlac funcLlon / myocardlal conLracLlllLy aL Lhls Llme can be broughL abouL by
supplemenLlng Lhe body's own response wlLh Lhe use of caLecholamlne agenLs 1hese wlll sLlmulaLe Lhe
acLlon of Lhe sympaLheLlc nervous sysLem
lor ease of undersLandlng and cllnlcal pracLlce Lhey can be slmply classlfled as elLher |notropes or
vasopressors Some drugs however do boLh


An |notrope ls an agenL whlch lncreases or decreases Lhe force of muscular conLracLlon of Lhe hearL lL
acLs on 1 2 recepLors
a|pha ( ) perlpheral vasoconsLrlcLlon
lncreased sysLemlc vascular reslsLance
beta 1( 1) lncreased hearL raLe
lncreased Av conducLlon veloclLy
lncreased venLrlcular conLracLlllLy
beta 2 ( 2) perlpheral vasodllaLlon
bronchodllaLaLlon


Inotropes and the|r react|ons
ALnA 8L1A 1 8L1A 2 CCMMLN1S

Dobutam|ne


++

+

Can be glven
perlpherally

Dopam|ne


+

++

+


AJteoolloe


++

+++

++
Can be glven
perlpherally lf
desperaLe

Noradrena||ne


+++

+



92
os|t|ve |notropes are known as sympaLhlomlmeLlc drugs 1hey sLlmulaLe conLracLlon dlrecLly affecLlng
hearL raLe perlpheral perfuslon blood pressure and urlnary ouLpuL
1hey lnclude dopamlne dobuLamlne and adrenallne
Negat|ve |notropes block adrenorecepLors ln Lhe hearL perlpheral vessels bronchl pancreas and llver
1hey lnclude labeLalol and propanolol
A vasopressor drug acLs on 1adrenerglc recepLors by lncreaslng perlpheral vascular Lone and lncreaslng
sysLemlc vascular reslsLance whlch leads Lo an elevaLlon of blood pressure
1hey lnclude adrenallne noradrenallne

ln Lheory lnoLropes LreaL lmpalred cardlac conLracLlllLy and vasopressors LreaL perlpheral vascular fallure
MosL drugs used for cardlovascular supporL wlLhln CrlLlcal Care dlsplay boLh lnoLroplc and vasopressor
acLlvlLy


Adrena||ne and noradrena||ne are vasoconstr|ct|ve sympathom|met|cs 1hey ralse Lhe blood pressure
LranslenLly by acLlng on Lhe adrenerglc recepLors Lo consLrlcL Lhe perlpheral vessels 8uL aL Lhe same
Llme Lhey reduce Lhe perfuslon of Lhe kldneys and oLher vlLal organs
Dopam|ne dobutam|ne and |soprena||ne are |notrop|c sympathom|met|cs uopamlne lsoprenallne acL
on Lhe recepLors ln Lhe cardlac muscle and lncrease conLracLlllLy wlLh llLLle effecL on Lhe hearL raLe
whereas dobuLamlne wlll lncrease Lhe hearL raLe


Ind|cat|ons for use to max|m|se card|ac output and oxygen de||very to the t|ssues when other measures
have fa||ed to ach|eve the des|red effect
1hey should be LlLraLed Lo provlde maxlmal LherapeuLlc effecLs wlLh mlnlmal slde or Loxlc effecL

1here is o very ropid onset ond ropid offset
LxcepL for mllrlnone whlch has abouL a 20 mlnuLe onseL and halfllfe of 46 hours

uown requ/otion
CrlLlcally lll paLlenLs can become reslsLanL Lo effecLs of pressor agenLs
1hls ls more prevalenL ln Lhose wlLh sepLlc shock

a|m
Lo opLlmlse dlsLrlbuLlon of cardlac ouLpuL
use mlnlmum effecLlve dose Lo achleve deslred ouLcome
Lo wean and dlsconLlnue Lo avold undeslrable slde effecLs





'f|ght f||ght' response

ln response Lo sLress or fear our bodles auLomaLlcally prepare Lhemselves for flghLlng or fleelng 1hls ls
an auLonomlc response
1he sympaLheLlc lmpulses lnlLlaLe an emergency" sysLem 1he ongolng sympaLheLlc slgnals lncrease
greaLly

93
1he body prepares to expend max|mum energy by
lncreaslng hearL raLe lncreases dellvery of oxygen and glucose Lo Lhe skeleLal muscles
lncreaslng conLracLlllLy lncreases raLe of blood flow and lncreases dellvery of oxygen and glucose
Lo Lhe skeleLal muscles
ullaLlon of coronary vessels of Lhe hearL lncreases oxygen and nuLrlenLs Lo Lhe cardlac muscles
Lo susLaln lncreased hearL raLe and conLracLlllLy
ConsLrlcLlon of blood vessels ln Lhe dlgesLlve and oLher organs shunLs blood Lo skeleLal muscles
Lo lncrease oxygen and glucose
ConLracLlon of spleen and oLher blood reserves lncreaslng general blood clrculaLlng Lhe body
whlch lncreases Lhe oxygen and glucose Lo Lhe skeleLal muscles
ullaLlon of resplraLory alrways lncreases Lhe oxygen load lnLo Lhe blood
lncreased replraLory depLh and raLe lncreases Lhe oxygen load lnLo Lhe blood
lncreased sweaLlng lncreased dlsslpaLlon of heaL generaLed by skeleLal muscle
lncreased converslon of glycogen lnLo glucose lncreases Lhe amounL of glucose avallable Lo Lhe
skeleLal muscle


In other words fasLer sLronger hearLbeaL dllaLed blood vessels ln skeleLal muscle dllaLed bronchl
lncreased blood sugar levels from converslon of glycogen Lo glucose

SympaLheLlc effecLors such as Lhe hearL smooLh muscle glands have recepLors for noradrenallne
8oLh adrenallne and noradrenallne can blnd Lo Lhe recepLors of Lhe sympaLheLlc effecLors Lo prolong and
enhance Lhe effecLs of Lhe sympaLheLlc sLlmulaLlon by Lhe auLonomlc nervous sysLem

ln slmple Lerms Lhe body produces adrenallne noradrenallne and dopamlne normally Lhls ls conLrolled
and can lncrease or decrease accordlng Lo Lhe body's need
ln sLress Lhe producLlon lncreases Lo provlde Lhe 'flghL or fllghL' response 1he effecLs on Lhe body are
deLalled below showlng Lhe sympaLheLlc recepLors as descrlbed above

1he body's coplng mechanlsm can only compromlse for so long before Lhe body's equlllbrlum ls
challenged and becomes unable Lo malnLaln normosLasls
lmprovemenL ln cardlac funcLlon/myocardlal conLracLlllLy aL Lhls Llme can be broughL abouL by Lhe use of
dopamlne dobuLamlne and adrenallne 1hese wlll lncrease Lhe hearL raLe aLrlovenLrlcular conducLlon
veloclLy and venLrlcular conLracLlllLy


When a ch||d presents as s|ck
When chlldren presenL as very slck Lhls flghL or fllghL response ls usually runnlng aL full LllL 1hey are
compensaLlng and runnlng aL maxlmum ouLpuL
Lower blood pressure ls a very laLe slgn of how slck Lhey are lluld boluses may help Lhe lmmedlaLe
slLuaLlon by lncreaslng Lhe clrculaLlng volume
94

When you glve Lhls chlld any sorL of sedaLlve or anaesLheLlc agenL for lnLubaLlon you are lmmedlaLely
Laklng away Lhelr flghL and fllghL response lL ls Lhls response LhaL has been malnLalnlng Lhelr hearL raLe
and blood pressure and once you Lake away Lhe drlve LhaL releases Lhe lncreased release of
caLecholamlnes Lhen Lhe chlld's cardlovascular funcLlon wlll plummeL 1helr hearL raLe may well drop
Lhelr 8 wlll fall and you have an lmmedlaLe emergency slLuaLlon

lf conslderlng lnLervenLlon and venLllaLlon ln Lhe slck chlld and Lhe blood pressure ls lowered lL ls wlse Lo
conslder maklng up lnoLropes prlor Lo lnLubaLlon
lf noL Lhen have emergency drugs at hand
lf Llme permlLs galn access glve resusclLaLlon flulds of 20mls/kg and reassess prlor Lo lnLubaLlng and
sedaLlng

lf lnoLropes are belng consldered Lhen Lhe chlld wlll need a loL of monlLorlng and consLanL revlew
uraw up some emergency drugs and make up some lnoLropes ofLen adrenallne and dopamlne Lo sLarL
wlLh
Cnce Lhe slLuaLlon ls sLablllsed Lhen conslder raLlonallslng Lhe lnoLropes buL lnlLlally Lhe adrenallne wlll
lncrease Lhe chlld's hearL raLe and cardlac ouLpuL and Lhe dopamlne wlll lncrease Lhe 8 and lmprove CC
noradrenallne may also be used buL dobuLamlne should only be lnlLlaLed once Lhe clrculaLlng volume /
Cv ls adequaLe


whot monitorinq do they need?
8ecause Lhese chlldren are recelvlng drugs LhaL have an lmmedlaLe and consLanL effecL on Lhelr cardlac
ouLpuL Lhey musL be consLanLly monlLored
PearL raLe
8lood pressure by an arLerlal llne
Cv
1emperaLure
urlnary ouLpuL
8lood sugar


why?
- effecLs of drugs conLlnually acL upon Lhe hearL and clrculaLlng volume Changes ln any parameLer
can lndlcaLe changes wlLhln Lhe chlld's condlLlon and musL be revlewed and reassessed 1helr
requlremenL for Lhe drug can change very qulckly
- changlng Lhe syrlnge over can have exLreme effecLs on Lhe hearL raLe and blood pressure so musL be
LlLraLed and changed very carefully observlng P8 8 conLlnually whllsL changlng over nLvL8 leL
Lhese syrlnges run ouL!





95
who con moke up inotropes?
All senlor sLaff and Lhose LhaL have underLaken Lralnlng and assessmenL can make up and check lnoLropes
wlLh any sLaff who have Lhelr lv cerLlflcaLe SLaff should noL change over Lhe syrlnges unless compeLenL
Lo do so or are belng supervlsed




drug ca|cu|at|ons
drug 3mgs x welghL ln S0 mls (dopamlne dobuLamlne C1n mllrlnone)
03mgs x welghL ln S0 mls (adrenallne noradrenallne lsoprenallne)

eg 20 kg ch||d to start an IVI of S mcg]kg]m|n of dopam|ne
3 x 20 60 mgs ln LoLal of S0 mls of S dexLrose
Lo calculaLe ouL change mgs lnLo mcgs x 1000 60000 mcgs
mcgs/ml / volume le S0 1200mcgs/ml
mcgs/ml/mln / Llme le 60 20mcgs/ml/mln
mcgs/kg/ml/mln / welghL le 20 1mcg/kg/ml/mln
Smcgs/kg/mln x raLe le S Smcgs/kg/mln

eg S kg ch||d to start an IVI of 02 mcgs]kg]m|n of adrena||ne
03 x S 1S mgs ln LoLal of S0 mls of S dexLrose
Lo calculaLe ouL change mgs lnLo mcgs x 1000 1S00 mcgs
mcgs/ml / volume le S0 300mcgs/ml
mcgs/ml/mln / Llme le 60 Smcgs/ml/mln
mcgs/kg/ml/mln / welghL le S 01mcg/kg/ml/mln
02 mcgs/kg/mln x raLe le 2 02mcgs/kg/mln


96
Adrena||ne ( Lp|nephr|ne)

Act|on
AcLs dlrecLly on alpha and beLa recepLors wlLh levels changlng accordlng Lo Lhe physlologlcal sLaLus
lmlLaLes mosL acLlons of SnS excepL for Lhe face sweaL glands
SLrengLhens myocardlal conLracLlon lncreaslng cardlac ouLpuL raLe
lncreases sysLemlc vascular reslsLance
lncreases coronary arLery perfuslon pressure lncreaslng myocardlal oxygenaLlon
lncreases sysLollc buL may decrease dlasLollc blood pressure
Causes bronchlal smooLh muscle relaxaLlon
ConsLrlcLs bronchlal arLerloles and lnhlblLs hlsLamlne release Lhls reduces congesLlon and
oedema lncreaslng Lldal volume and vlLal capaclLy
ConsLrlcLs arLerloles ln Lhe skln mucous membranes and kldneys
ullaLes skeleLal muscle blood vessels
8alses blood sugar by promoLlng converslons of glycogen reserves ln Lhe llver Lo glucose and
lnhlblLs lnsulln release ln Lhe pancreas
CnS sLlmulaLlon belleved Lo resulL from perlpheral effecLs

Uses
card|ac arrest
sympLomaLlc bradycardla unresponslve Lo venLllaLlon and oxygen
poor sysLemlc perfuslon
hypotens|on w|th good CV and stab|e rhythm
anaphylacLlc reacLlons
acuLe asLhmaLlc aLLack
Lemporary rellef of bronchospasm

Dose arrest 01ml/kg of 110 000 (001mg/kg)
8epeaL as necessary
IVI slngle sLrengLh made up as 03mg/kg ln S0mls S glucose
01mcg/kg/mln aL 1ml/hr
oJjost tote ootll nk / 8l ot systemlc petfosloo teocbes occeptoble level
nebu||ser 1ml of 11000 adrenallne dlluLed wlLh 3mls sallne

precaut|ons ] s|de effects
meLabollc acldosls may decrease effecL so should be correcLed
LachyarryLhmlas
hyperLenslon
hyperglycaemla
lncreased myocardlal oxygen demand
raLes hlgher Lhan 06mcg/kg/mln cause profound vasoconsLrlcLlon LhaL can compromlse
exLremlLles and skln perfuslon
lower doses may decrease renal and hepaLlc blood flow
lnfllLraLlon causes necrosls and lschaemla
sysLemlc reacLlons nervousness resLlessness anxleLy Lremors nausea sweaLlng vomlLlng
dyspnoea weakness dlzzlness
bronchlal and pulmonary oedema
urlnary reLenLlon
97
noradrena||ne

Act|on
acLs dlrecLly on alpha adrenerglc recepLors
acLs llLLle on beLa recepLors excepL on Lhe hearL
maln LherapeuLlc effecL vasoconsLrlcLlon cardlac sLlmulaLlon
reduces blood flow Lo Lhe kldney oLher vlLal organs skln skeleLal muscle
perlpheral vasoconsLrlcLlon
lnoLroplc sLlmulaLlon of Lhe hearL whlch causes an
lncrease ln sysLollc and dlasLollc pressure
myocardlal oxygenaLlon
coronary arLery blood flow
myocardlal ouLpuL
cardlac ouLpuL varles wlLh sysLemlc blood pressure
bradycardla
causes less CnS sLlmulaLlon and less effecL on meLabollsm Lhan adrenallne
large doses can cause glycogenolysls and lnhlblLs pancreaLlc release of lnsulln so causlng
hyperglycaemla

uses
resLore blood pressure ln acuLe hypoLenslve sLaLes pr|mar||y used |n shock
cardlac arresL
useful ln hypercyanoLlc eplsodes llke lalloLs 1rlcuspld aLresla Lo overcome perlpheral
vasodllaLlon
useful ln pulmonary vascular dlsease Lo overcome perlpheral sysLemlc vasodllaLlon
sepsls wlLh slgnlflcanL vasodllaLlon

dose 03mg/kg ln S glucose aL 1ml/hr 1mcg/kg/mln
001 0Smcgs/kg/hr

precaut|on ] s|de effects
slgnlflcanLly lncreases myocardlal workload
reducese perlpheral Llssue perfuslon
may cause hypoxla or hypercapnla
hyperLenslon
bradycardla
arryLhmlas
resplraLory dlfflculLles
headache
Llssue necrosls aL lnfuslon slLe
CnS Lremors dlzzleness resLlessness anxleLy weakness
Pyperglycaemla
rolonged use plasma volume depleLlon
Cedema
Paemorrhage
lnLesLlnal hepaLlc and renal necrosls




98
uopamlne

4ction
2Smcg/kg/mln lncreases renal bloodflow (u recepLors)
splanchlc
coronary
cerebral blood flow
S10mcg/kg/mln lncreases cardlac conLracLlllLy wlLhouL ralslng P8 8
lncreases cardlac ouLpuL
dlrecL sLlmulaLlon of cardlac 8 1 adrenerglc recepLors
lndlrecL cardlac sLlmulaLlon Lhorough Lhe release of noradrenallne sLored
ln cardlac sympaLheLlc nerves
may cause a recuLlon ln cardlac ouLpuL ln neonaLes
1020mcg/kg/mln vasoconsLrlcLlon
lncreases vascular reslsLance
Lachycardla


uses
low cardlac ouLpuL
hypoLenslon
poor perlpheral perfuslon when adequaLe lnLravascular volume and sLable rhyLhm


dosage 3mg/kg ln S0mls S glucose aL 1ml/hr 1mcg/kg/mln slngle sLrengLh
210mcg/kg/mln

precaut|ons ] s|de effects
Lachycardla
lncreased oxygen demand from myocardlum
arryLhmlas especlally Sv1 v1
hyperLenslon
20mcgs/kg/mln or more vasoconsLrlcLlon perlpherally and lschaemla ln Lhe shocked chlld
cenLral lnfuslon only lf more Lhan Smcgs/kg/mln
local lschaemla and necrosls lf exLravasaLlon of perlpheral lvl
lnacLlvaLed ln alkallne soluLlons












99
uobuLamlne

4ction
SynLheLlc caLecholamlne
AcLs dlrecLly on 8adrenerglc recepLors noL dependenL on noradrenallne sLores
lncreases cardlac conLracLlllLy
lmproves cardlac ouLpuL
lncreased hearL raLe wlLh mlld perlpheral dllaLlon of vascular bed
lncreases cardlac ouLpuL ln cardlogenlc shock
uecreases pulmonary caplllary pressure and sysLemlc vascular reslsLance
Less effecLlve Lhan adrenallne ln sepLlc shock as lL may lncrease exlsLlng sysLemlc vasodllaLlon

uses
Pypoperfuslon lf assoclaLed wlLh sysLemlc vascular reslsLance
Severe congesLlve cardlac fallure
Cardlogenlc shock especlally lf caused by cardlomyopaLhy as lL decreases perlpheral
vascular reslsLance

Dose 3mg/kg ln S0mls S glucose 1mcg/kg/mln aL 1ml/hr
S10mcg/kg/mln
ad[usL raLe as requlred Lo sLablllse 8 and perfuslon

recaut|ons and s|de effects
Lachycardla
LachyarrhyLhmlas
ecLoplc beaLs
nausea / vomlLlng
hyperLenslon
exLravasaLlon Llssue necrosls lschaemla
lnacLlvaLed slowly lf ln alkallne soluLlons





100
M||r|none

A selecLlve lnhlblLor of phosphodlesLerase lll an enzyme responslble for caLalyslng Lhe breakdown of
cAM
lound ln hlgh concenLraLlon ln cardlac and vascular smooLh muscle

AcLlon
lnhlblLlon of phosphodlesLerase lll leads Lo accumulaLlon of cAM (cycllc adenoslne
monophosphaLe) resulLlng ln
a poslLlve lnoLrope reacLlon and
vasodllaLlon
an lnoLrope and afLerload reducer (lnodllaLor)
8ronchodllaLaLlon
SllghLly lncreases hearL raLe
lncreases conLracLlllLy
Vasod||at|on |n ske|eta| musc|e

Uses
congesLlve cardlac fallure
decreased cardlac ouLpuL and
lncreased fllllng pressure
posL cardlac surgery
Mllrlnone has abouL a 20 mlnuLe onseL and halfllfe of 46 hours
Can be glven perlpherally

Dose Loadlng S0mcg/kg over 1020 mlns
1hen 03 07S mcg/kg/mln
n8 a monograph wlll be speclflcally calculaLed for each lndlvldual chlld lndlcaLlng Lhe dose and volume Lo
be made up harmacy wlll prepare Lhls aL Lhelr earllesL convenlence
Powever should Lhe chlld come ln aL nlghL Lhen Lhe followlng ls recommended
dlluLe a 10ml ampoule lnLo 2Smls of S glucose Lo glve 400mcg/ml
1hls ls Lhe mosL concenLraLed sLrengLh able Lo be glven perlpherally
lf Lhe chlld has a cenLral llne Lhen dlluLe 20mlsof mllrlnone lnLo 2Smls of soluLlon 1hls would
glve a sLrengLh of 800mcg/ml
lf Lhe chlld ls very fluld resLrlcLed Lhen lL can be glven neaL

recauLlons / slde effecLs
hypoLenslon conslder a fluld bolus when lnlLlaLlng LreaLmenL
arrhyLhmlas
lncompaLlble wlLh frusemlde preclplLaLlon

101

Isoprena||ne


Act|on
8adrenerglc agonlsL
lncreased hearL raLe
lncreased aLrlal venLrlcular conducLlon
lncreased cardlac conLracLlllLy
lncreased myocardlal oxygen consumpLlon causes perlpheral vasodllaLlon parLlcularly ln
skeleLal muscle
Cardlac ouLpuL lncreases lf clrculaLlng blood volume adequaLe
ulse pressure lncreases because dlasLollc pressure falls wlLh dllaLlon of Lhe blood vessels
8ronchodllaLlon

Uses
Cenerally now used as a shorL Lerm emergency LreaLmenL of hearL block or severe
bradycardla
bradycardla wlLh poor perfuslon adrenallne may be preferred as lL ls less llkely Lo
decrease dlasLollc pressure


dose 03mg/kg ln S0mls S glucose aL 1ml/hr 01mcg/kg/mln
010Smcg/kg/mln
may requlre Lo go up Lo 1mcg/kg/mln buL resulLs ln Lachycardla

recaut|ons ] s|de effects
lsoprenallne may compromlse coronary perfuslon because lL has no alphaadrenerglc effecLs and
decreases dlasLollc pressure
lncreases myocardlal oxygen consumpLlon by lncreaslng myocardlal conLracLlllLy and hearL raLe
lncreased hearL raLe may furLher decrease coronary perfuslon by decreaslng dlasLollc fllllng Llme
nC1 glven ln arresL
lsoprenallne cardloLoxlclLy followlng lvl wlLh asLhmaLlc chlld
arrhyLhmlas
Lachycardla
hypoLenslon
sweaLlng
headache







102
G|ycery| 1r|n|trate

Act|on
SysLemlc venous and arLerlal vasodllaLor
ulmonary vasodllaLlon
8elaxes sLlff venLrlcles
AcLs on velns and coronary vessels
oLenL coronary vasodllaLor
uecreases venous reLurn and Lherefore decreases lefL venLrlcular work

Uses
LefL venLrlcular fallure

Dose 3mcg/kg ln S0mls S glucose aL 1ml/hr 1mg/kg/mln
0SSmcg/kg/mln

precaut|ons ] s|de effects
maxlmum concenLraLlon 1mg/ml
Lachycardla care wlLh admlnlsLraLlon
non vC glvlng seL reacLlve Lo llghL
hypoLenslon
headache
flushlng
dlzzlness
hypoLhermla



103
ropano|o|

act|on
nonselecLlve beLa blocker of cardlac and resplraLory adrenorecepLors
compeLes wlLh adrenallne and nonadrenallne for avallable beLarecepLor slLes
blocks cardlac effecLs of beLaadrenerglc sLlmulaLlon causlng decreased hearL raLe and decreased
myocardlal lrrlLablllLy
decreased force of conLracLlon
depresses auLomaLlclLy of slnus node and ecLoplc pacemaker
hlgher doses depress cardlac funcLlon
also blocks Lhe bronchodllaLor effecL of caLecholamlnes and decreases plasma levels of free faLLy
aclds
promoLes sodlum reLenLlon ofLen need a dlureLlc
decreased plaLeleL aggregablllLy
renlnacLlvlLy suppressed along wlLh beLa blocker effecL causes decreased cardlac ouLpuL causlng
hypoLenslon

uses
hyperLenslon
arryLhmlas and LhyroLoxlc crlsls
obsLrucLlve cardlomyopaLhy
myocardlal lnfarcLlon
Lachycardla's assoclaLed wlLh dlgoxln LoxlclLy
anaesLhesla
hyperLrophlc subaorLlc sLenosls

dose 002mg's/kg LesL dose
Lhen 01mg/kg (max Smg) over 10 mlns
repeaL x 13 prn
Lhen 0103mg/kg/dose 3 hourly

precaut|ons ] s|de effects
prurlLls rash allergy
fever
resplraLory dlsLress
CnS psychosls sleep dlsLurbances depresslon confuslon aglLaLlon faLlgue syncope weak
drowsy halluclnaLlons
CvS palplLaLlons profound bradycardla Av hearL block hypoLenslon LachyarryLhmla acuLe CCl
Lar eye vlsual dlsLurbances con[uncLlvlLls LlnnlLus
Cl nausea vomlLlng dlarrhoea consLlpaLlon abdomlnal palns hypoglycaemla
PaemaLology nonLhrombocyLopenlc purpura anaemla's hypocalcaemla
8esp dyspnoea laryngospasm bronchospasm
SkeleLal muscle vasoconsLrlclLlon