Ronald V.

Limchiu, MD, FPPS, FSPCCMP

 Vasoconstrictors
◦ Dopamine (High Dose >5mcg/kg)
◦ Epinephrine
◦ Norepinephrine
◦ Vasopressin
 Vasodilators
◦ Dopamine (low dose (<5mcg/kg)
◦ Dobutamine
◦ Milrinone
 Indications
 To improve cardiac output and perfusion by
manipulating vascular tone after fluid
resucitation
WARM SHOCK COLD SHOCK

Warm flushed skin Cold clammy skin

Bounding pulses Faint or absent pulses
Normal to widened pulse Narrow pulse pressure
pressure (<20mmHg)
Normal BP Low BP
 AGE SYSTOLIC BLOOD PRESSURE
Term neonates (0-28 days) <60mmHg
Infants (1-12mos) <70mmHg
Children 1-10years <70mmHg +
(5th BP Percentile) (age in years x2 mmHg)
Children > 10 years <90mmHg
 Indications: Vasoactive agents in shock

 What to start?
◦ W nearer to N, C nearer to E
◦ Warm Shock start with norepinephrine
◦ Cold Shock start with epinephrine
 Start with NOREPINEPHRINE
INCREASE EVERY 20-30 MINUTES
UNTIL BP or PERFUSION IMPROVES

 IF NO IMPROVEMENT AFTER DOSE OF NE >1MCG/KG/MIN

 Add on VASOPRESSIN or EPINEPHRINE

 After no improvement with ass on vasoconstrictors,

 CONSIDER VASODILATORS
 Start with EPINEPHRINE

IF NO IMPROVEMENT AFTER DOSE OF Epi >1mcg/kg/min

Add on Vasodilator: DOBUTAMINE or MILRINONE

If Patient is bleeding or with hepatorenal organ dysfunction

CONSIDER VASOPRESSIN
Concentration = Preparation
x 1000
50mL

Milligram (mg) to microgram (mcg)

multiply by 1000
Rate = Weight x Recommended Dose x 60
Concentration

=
Kg x mcg/kg/min x 60min/hr
mcg/mL
Rate = mL/hr
 Preparation: 2mg/2mL. 4mg/mL, 16mg/3mL
 RD: 0.1 – 2mcg/kg/min
 Weight: 10kg
 Concentration = 40mcg/mL 2mg x 1000
50mL

10kg x 0.1mcg/kg/min x 60
 Dose = 40mcg/mL

= 1.5mL/Hr
To Order:
- Norepinephrine: 2mg/2ml ampule
+ D5W 48mL
Total of 50ml in infusion pump
to run at 1.5mL/hr
(wt 10kg, AD 0.1mkm) (conc 40mcg/mL)
 Preparation: 1mg/mL
 RD: 0.1 – 1mcg/kg/min
 Weight: 10kg
 Concentration = 1mg/mL x 1000
50mL

=20mcg/mL

1 amp in 49Ml D5W = 20

2 amps in 48mL D5W = 40
3 amps in 47mL D5W = 60
4 amps in 46mL D5W = 80
 Dose = 10kg x 0.1mcg/kg/min x 60 = 3mL/Hr
20mcg/mL

To Order:
- Epinephrine: 1mg/1ml ampule
+ D5W 48mL
Total of 50ml in infusion pump
to run at 3mL/hr
(wt 10kg, AD 0.1mkm) (conc 20mcg/mL)

 Preparation: 40mg/mL, 200mg/5mL
 Recommended dose
1-5mcg/kg/min Vasodilation, increase renal and splanchnic
circulation
5-10mcg/kg/min Increase heart contraction without effect in
the heart rate
10-20mcg/kg/min Increase blood pressure
 Weight: 10kg
 Concentration = 40mg/mL x 1000
50mL

=800mcg/mL

10kg x 5mcg/kg/min x 60
 Dose = 800mcg/mL

=3.75mL/hr
To Order:
- Dobutamine: 250mg/5ml ampule
+ D5W 45mL
Total of 50ml in infusion pump
to run at 0.6mL/hr
(wt 10kg, AD 5mkm) (conc 5000mcg/mL)
 Preparation: 10mg/mL
 Recommended dose:
◦ Loading Dose: 50-75 mcg/kg in 20min
(dilute with 10-20mL NSS or D5W)
◦ Maintenance Dose: 0.25 – 0.75 mcg/kg/min
 Preparation: 10mg/mL
 Recommended dose:
◦ Loading Dose: 50-75 mcg/kg in 20min
(dilute with 10-20mL NSS or D5W)
=50mcg x 10kg in 20mins
=500mcg
=0.5ml loading dose of milrinone
 Maintenance Dose
◦ Concentration = 10mg x1000
50mL

=200mcg/mL

◦ Dose = 10kg x 0.25mcg/kg/min x 60

200mcg/mL

=0.75mL/hr (Mainenance dose)

To Order:
- Milrinone: 10mg/10mL ampule, give 0.5mg
+ 9.5mL D5W
at 0.5mL over 20min as loading dose
Then,
give 1 ampule milrinone
+40mL D5W at 0.75mL/hr as maintenance dose
(AD 0.25mkm) (conc 200mcg/mL)
 Preparation: Terlipressin 1mg/5mL (200mcg/mL)
 Recommended dose:
◦ Loading Dose: 20-40mcg/kg IV Bolus
◦ Maintenance dose: 4-20mcg/kg q6h to 8h IVTT
 Weight: 10kg
 Maintenance Dose:
= 20mcg x 10kg
= 200mcg/kg
=1mL q6 to 8H IVTT (maintenance dose of terlipressin)