Cardiovascular Critical Care II
Medication
Typical Dosing
Range
(mcg/kg/min)
Clinical Pearls
Dopamine
2β20
In general, dose-related receptor activity:
2β5 mcg/kg/min dopamine receptor,
5β10 mcg/kg/min Ξ²1-receptor,
> 10 mcg/kg/min Ξ±1-receptor
Does not provide exclusive receptor activity across dosing ranges and, thus,
can be arrhythmogenic at any dose
Use cautiously in patients with a history of heart disease or arrhythmias
Useful for patients with bradycardia and hypotension
Dobutamine
2β20
Predominance of inotropic properties but with activity on Ξ²1 > Ξ²2 > Ξ±1-receptor
Used to treat low cardiac output
Ξ±1-agonist and Ξ²2-agonist counterbalance, leading to little change in systemic
vascular resistance
Can lead to vasodilation in select patients
Less systemic or pulmonary vasodilation than milrinone
More tachycardia than milrinone but similar risk of ventricular arrhythmias
Use cautiously in patients with a history of arrhythmias
Milrinone
0.25β0.75
Phosphodiesterase type 3 inhibitor leading to increased intracellular cAMP
leading to influx of calcium and subsequently inotropy and chronotropy
Used to treat low cardiac output
Loading dose rarely used because of significant systemic hypotension
Longer duration of activity than dobutamine
Accumulates in renal dysfunction
More systemic and pulmonary vasodilation than dobutamine
Less tachycardia than dobutamine but similar risk of ventricular arrhythmias
Use cautiously in patients with a history of arrhythmias
aSee chapter on shock for a detailed discussion regarding selection of agent, dosing, pharmacology, and clinical considerations.
SBP = systolic blood pressure
ii.
Glucose management (Circulation 2010;122:S768-786; Circulation 2008;118:2452-83)
| (a) | Avoidance of severe hypoglycemia (40 mg/dL or less) |
|---|---|
| (b) | Target moderate glucose control: 144β180 mg/dL |
| (c) | May require continuous insulin infusion to maintain goals |
iii.
and seizures, or both, can occur in up to 35% of adult patients who achieve ROSC and are more
common in those who remain comatose. Electrographic patterns seen in the patient population
include electrographic seizures, status epilepticus, and ictal-interictal continuum patterns
| (a) | Clonazepam, valproic acid, and levetiracetam are all effective for myoclonus, but |
|---|
clonazepam should be considered first line.
| (b) | Benzodiazepines, phenytoin, valproic acid, propofol, and barbiturates are all effective for |
|---|
postβcardiac arrest seizures. Seizures and status epilepticus are treated similarly to non-
cardiac arrest populations. For dosing and monitoring guidelines, see the Status Epilepticus
section of the Neurocritical Care chapter.