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Hemodynamic Formula
MAP CVP
=
=
=
=
CVP
MAP
V = IR
CO x SVR
P = QR
SV x HR x SVR
(EDV ESV) x HR x SVR
EDV x (EDV ESV) x HR x SVR
EDV
= EDV x (EDV ESV) x HR x SVR
EDV
= EDV x EF x HR x SVR
Preload
Rhythm
Contractility
Afterload
Optimization
Provide adequate O2
delivery
Optimize CO, SvO2, lactate
Provide organ support
Minimize complications
Wean from vasoactive
agents
Achieve negative fluid
balance
Stabilization
De-escalation
Adrenergic receptor
Alpha-1
receptor
Vasoconstri
ction
Mydriasis
Increase
internal
sphincter
tone of
bladder
Alpha-2
receptor
Inhibition
of NE
release
Inhibition
of Ach
release
Inhibition
of insulin
release
Beta-1
receptor
Tachycardia
Increase
cardiac
contractility
Increase
lipolysis
Increase
renin
release
Beta-2
receptor
Vasodilatat
ion
Bronchodil
atation
Increase
glycogenol
ysis
Increase
glucagon
release
Relax
uterine
smooth m.
Venoconstriction
-2
0
Pra, CVP
Vasoconstriction
Adrenergic drugs
Dobutamine
Dopamine
(moderate
dose)
Alpha
Beta-1
Beta-2
++
+++
+
+++
Dopamine (high
dose)
Epinephrine
++
+++
+++
+++
++++
+++
Norepinephrine
Phenylephrine
+++
+++
+
-
Milrinone
Dopamine
Low dose (< 5 (3) g/kg/min) : activates
dopamine-specific receptors
Increase in natriuresis and urine output
Renal effects are minimal or absent in
patients with AKI
Dopamine
Moderate infusion rates (5 (3) 10
g/kg/min) : stimulates -Receptors in the
heart and peripheral circulation
Increase in myocardial contractility and
heart rate
Dopamine
High infusion rates (>10 g/kg/min) : dosedependent activation of alpha-receptors in
the systemic and pulmonary circulations
vasoconstriction
Clinical use
Cardiogenic shock : mechanical assist devices are
preferred for cardiogenic shock
Septic shock : norepinephrine is preferred for septic
shock
Dosage : Dopamine 200 (250) mg in NSS 100 (125) mL
Started at a rate of 35 g/kg/min (without a loading dose)
Increments of 35 g/kg/min to achieve the desired effect
Should be delivered into central veins
Dobutamine
Alpha
Beta-1
Beta-2
++
Dobutamine
Positive inotropic effect
Positive chronotropic effect
Peripheral vasodilatation
Increase in cardiac work and myocardial O2 consumption
Clinical use
Decompensated heart failure due to systolic dysfunction
Myocardial depression associated with septic shock
Dosage : Dobutamine 200 mg (250 mg) in NSS 100 (125) mL
Started at an infusion rate of 35 g/kg/min, increments of 3
5 g/kg/min
Norepinephrine
Norepinephrine
Alpha
Beta-1
Beta-2
+++
Vasoconstriction
Epinephrine
Epinephrine
Alpha
Beta-1
Beta-2
+++
++++
+++
Vasoconstriction
Vasodilatation
Bronchodilatation
Phenyleprine
Phenylephrine
Alpha
Beta-1
Beta-2
+++
Vasoconstriction
Bradycardia, decrease in stroke volume (usually in patients with
cardiac dysfunction), hypoperfusion of the kidneys and bowel
Clinical use : Hypotension from spinal anesthesia, limit usage in
critical care setting
Dosage : initial IV dose is 0.2 mg, which increments of 0.1 mg
to a maximum dose of 0.5 mg, rate 0.10.2 mg/min
Vasopressin
Binding to V1A receptors on vascular smooth muscle
Remains unclear benefits : relative vasopressin
deficiency, hypersensitivity, or both
Dosage
0.0 1 to 0.05 units/min as an adjunctive agent in the
treatment of vasodilatory septic shock
40 units in CPR
Milrinone
Combine inotropic and vasodilating properties
(inodilator)
Phosphodiesterase inhibitor, Decreasing the metabolism
of cyclic AMP
May also be useful when -adrenergic receptors are
down-regulated or in patients recently treated with betablockers
Calcium
Indication
Hypocalcemia
Hyperkalemia --- Bradyarrythmia
Beta blocker/ calcium channel blocker overdose
Refractory hypotension
Dosage :
10% calcium gluconate 10-30 mL slowly push
10% calcium chloride 5-10 mL slowly push
Ud/min (mL/hr)
Ud/min (mL/hr)
= 6 x dose (ug/min)
100 x conc.
Concentration
= mg/ mL
Dopamine
If not response : NE
If BP stable
: Dobutamine
: Milrinone
(0.375-0.75 ug/kg/min
NE
Refractory shock
: Epinephrine
: Mechanical devices IABP, LVAD, ECMO,
transplantation
HR < 50/min
Symptom : shock, chest pain, syncope, alteration of
consciousness, HF
Atropine
If not response
: TCP
: Dopamine 2-10 ug/min
: Epinephrine 2-10 ug/min
Consider early use of TCP, epinephrine
Septic Shock
MAP CVP = preload x contractility x HR x afterload
Within 3 hrs
Within 6 hrs
5) Vasopressors (for
hypotension that does not
respond to initial fluid
resuscitation) to maintain
MAP 65 mmHg
6) In the event of persistent
arterial hypotension despite
volume resuscitation (septic
shock) or initial lactate 4
mmol/L):Meausure
- CVP
- ScvO2
7) Remeasure lactate if initial
lactate was elevated
Phenylephrine
Vasopressin
For microcirculation
Dobutamine
Reverse hypotension
Rapid assessment of volume status :
CVP, PCWP, echo
Fluid challenge test : if CVP < 5 mmHg
Early vasopressor use : NE, Dopamine
Pulmonary vasodilator
Inhaled epopostrenol/ NO
If not hypotension : IV epopostrenol
or oral sidenafil
Contractility
Dobutamine
Milrinone
Neurogenic Shock
MAP CVP = preload x contractility x HR x afterload
Adrenal Crisis
MAP CVP = preload x contractility x HR x afterload
Norepinephrine
Hydrocortisone
Anaphylactic shock
MAP CVP = preload x contractility x HR x afterload
Intramuscular
epinephrine
(1:1000) 0.3-0.5
mL
Epinephrine IV drip
if no response
Antihistamine
Hydrocortisone
Others : Beta 2agonist, oxygen