Pediatric Shock Part 9 Medications

Medications
·         Inotropic agents
·         Vasopressors
·         Vasodilators
·         Inodilators

Epinephrine
·         Acts directly on adrenergic receptors
·         Low dose cause increased myocardial contractility, heart rate, pulse pressure, and SBP
·         Higher doses produce increased SBP and DBP pressures and a narrowing of the pulse pressure.

Epinephrine Indications
·         Inadequate cardiac output
·         Hypotension
·         Symptomatic bradycardia
·         Pulseless arrest
·         Septic shock

Dosages
0.1-1mcg/kg/min infusion
Wide variety of response so the nurse should titrate it according to the patient’s response.
Mix 0.6 x body weight (kg) equals mg to add to sufficient fluid to create a total volume of 100ml.
1ml/hr delivers 0.1mcg/kg/min


Precautions
·         Preferably use a central line
·         Can cause local ischemia if infiltration occurs
·         Inactivated by alkaline solutions
·         May cause peripheral ischemia and necrosis if administered in peripheral line
·         May aggravate myocardial ischemia and increase myocardial oxygen demand

Norepinephrine
·         At clinical doses vasoconstrictive properties predominate
·         When used in combination with Dopamine or Dobutamine, it has been shown to increase splanic and renal artery perfusion

Norepinephrine indications
·         Hypotension, especially due to vasodilation
·         Inadequate cardiac output
·         Spinal shock
·         Alpha adrenergic overdoses: Tricyclic overdose and neuroleptic agents

Dosages
·         0.1-2mcg/kg/min infusion
·         Wide variety of response so the nurse should titrate it according to the patient’s response.
·         Mix 0.6 x body weight (kg) equals mg to add to sufficient fluid to create a total volume of 100ml.
·         1ml/hr delivers 0.1mcg/kg/min

Precautions
·         Hypertension
·         Organ ischemia
·         Distal extremity ischemia
·         Infuse via a secure central line
·         Extravasation can result in local tissue necrosis

Dopamine
·         Lower dose lead to increased renal and splanchnic, coronary, and cerebral blood flow
·         Higher dose lead to peripheral vasoconstriction and heart rate.
·         Wide variety in patient responses

Indications
·         Inadequate cardiac output
·         Hypotension
·         Need to increase renal and splanchnic blood flow

Precautions
·         May produce tachycardia which may aggravate myocardial ischemia
·         Deliver through a secure large bore peripheral cath
·         Higher does should be delivered via a central line
·         Avoid mixing with alkaline solutions

Dobutamine
·         Increases cardiac contractility
·         Increases heart rate
·         Produces mild vasodilation of the peripheral vascular bed

Indications
·         Myocardial dysfunction
·         Inadequate cardiac output, especially in patients with increased pulmonary vascular resistance

Dosages
·         2-20mcg/kg/min infusion
·         Preparation:  6 x body wt (kg) equals amount in mg to be added to sufficient diluent to create a total volume of 100ml
·         1ml/hr delivers 1mcg/kg/min

Precautions
·         Tachycardia
·         Tachydysrrhythmias
·         Hypertension
·         N&V
·         Local tissue necrosis due to extravasation

Sodium Nipride
·         Vasodilator that reduces vascular tone
·         It improves myocardial function by reducing peripheral vascular resistance

Indications
·         Hypertensive emergencies
·         Inadequate cardiac output due to high peripheral vascular resistance
·         Cadiogenic shock

Precautions
·         Monitor BP closely
·         Hypotension is the most common side effect
·         Monitor thiocyanide levels if used for more than 2-3 days

Milrinone
An inodilator that increases myocardial contractility and produces peripheral and vascular bed vasodilation

Indications
·         Inadequate cardiac output due to increased peripheral vasoconstriction
·         Cardiogenic shock
·         Septic shock

Dosages
·         Loading dose of 50-75mcg/kg over 10-60 minutes
·         Continuous infusion of 0.5-0.75mcg/kg/min IV/IO

Precautions
·         Monitor for hypotension during loading dose
·         Long half-life
·         Thrombocytopenia may occur

Inamrinone
·         Loading dose of 0.75 to 1mg/kg over 5 minutes. May repeat x 2 for total loading dose of 3mg
·         Continuous infusion of 5-10mcg/kg/min


Source:

Pediatric Advanced Life Support Provider Manual by Leon, M.D. Chameides, Ricardo A., M.D. Samson, Stephen M., M.D. Schexnayder and Mary Fran, RN Hazinski (Oct 12, 2011)



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