Dopamine

Clinical Uses
Treatment of hypotension, low cardiac output,
poor perfusion of vital organs

used to increase mean arterial pressure in

septic shock patients who remain hypotensive
after adequate volume expansion
 Mechanism of action
Classification: Adrenergic and dopaminergic cardiac
stimulants

 Dopamine stimulates dopaminergic receptors at lower

doses producing renal and mesenteric vasodilation
 At higher doses, it stimulates both dopaminergic and β1-
adrenergic receptors producing cardiac stimulation and
renal vasodilation
 Large doses stimulates α-adrenergic receptors.

Onset: Within 5 min.

Duration: <10 min.
 Dosage
IV Initial: 2-5 mcg/kg/min. May increase
gradually up to 5-10
mcg/kg/min.

Seriously ill patient: Up to 20-50 mcg/kg/min.

May increase infusion by 1-4 mcg/kg/min at 15-

30 min intervals until optimum response
obtained
Titrate to desired response
 Dosage
 1-5 mcg/kg/min IV (low dose): May increase urine
output and renal blood flow

 5-15 mcg/kg/min IV (medium dose): May increase

renal blood flow, cardiac output, heart rate, and
cardiac contractitlity

 20-50 mcg/kg/min IV (high dose): May increase

blood pressure and stimulate vasoconstriction; may
not have a beneficial effect in blood pressure; may
increase risk of tachyarrhythmias
 Administration
Stock dose: 200 mg per 5 mL ampule

IV Incompatibilities: Sodium bicarbonate 5%

IV Compatibilities: Most common solvents (eg,
D5W, D10W, dextrose/saline,
LR, NS)
IV Preparation
Dilute 200-400 mg in 250-500 mL of compatible
diluent (eg, D5W, NS, LR, D5/NS, D5/LR); typical
concentration range is 0.8-1.6 mg/mL, though up to
3.2 mg/mL has been used
 Administration
 Drug is stable for 24 hours after dilution
 Premixed solution may be administered without
dilution
 Do not use if solution is darker than slightly yellow;
discoloration to brown, pink, or purple indicates
decomposition
 Use infusion pump to control flow rate

 Titrate dosage to desired hemodynamic values or

optimal urine flow
Dobutamine
 CLINICAL USES
 indicated when parenteral therapy is
necessary for inotropic support in the short-
term treatment of adults
with cardiac decompensation due to
depressed contractility resulting either from
organic heart disease or from cardiac surgical
procedures.
 Mechanism of Action
Classification: Adrenergic and dopaminergic cardiac
stimulants

Dobutamine exerts positive inotropic effect on the

myocardium by stimulating β1-adrenergic receptors,
thereby increasing myocardial contractility, stroke
volume and cardiac output.

Onset: 1-10 min

Duration: 10 min
 Dosage
Acute heart failure
 2.5-10 mcg/kg/min, adjust according to response.
Dose range of 0.5-40 mcg/kg/min may be
given. Adjust according to patient's BP, heart rate,
cardiac and urine output.

Cardiac stress test

 5 mcg/kg/min for 8 min via infusion pump. Increase
dose by increments of 5 mcg/kg/min up to max 20
mcg/kg/min, w/ each dose being infused for 8 min
before the next increase
 Administration
Stock dose: 250 mg per 5 mL
IV Incompatibilities: Sodium bicarbonate 5%
IV Compatibilities: Most common solvents (D5/LR,
D5/NS, D5W, LR, NS)
IV Preparation:
Solution: Dilute 250 mg in 250 mL of compatible solution to
yield final concentration of 1000 mcg/mL; not to exceed
5000 mcg/mL

 Infuse into large vein via infusion pump

 Store intact vials at room temperature; protect from
excessive heat or freezing conditions
 Diluted solutions may be stored for 24 hours
Norepinephrine
(Levophed)
 CLINICAL USES
 Emergency measure in blood pressure
restoration in cases of acute hypotension.
 Mechanism of action
Classification: Vasoconstrictors

Norepinephrine is a direct-acting sympathomimetic

which stimulates β1- and α-adrenergic receptors.
Its α-agonist effects cause vasoconstriction,
thereby raising systolic and diastolic BP with
reflex slowing of heart rate.
 Dosage
Acute hypotensive states :
 Initial: 8-12 mcg/min, up to 8-30 mcg/min in refractory shock.
Adjust according to BP response. Maintenance: 2-4 mcg/min
 Infuse using a solution of 4 mcg/ml in glucose 5%, or sodium
chloride 0.9% and glucose 5% at a rate of 2-3 ml/minute.
Adjust according to BP response.

 Average maintenance dose: 0.5-1 ml/minute (2-4

mcg/minute).

 Infuse via a central venous catheter or into a large vein.

 Administration
IV Compatibility:
Dilute with 5% glucose injection, with or without sodium chloride; dilution with
sodium chloride injection alone is not recommended.
IV incompatibility:
Intravenous:
Incompatible with alkali and oxidising agents, barbiturates, chlorphenamine,
chlorothiazide, nitrofurantoin, novobiocin, phenytoin, sodium bicarbonate,
sodium iodide, streptomycin, insulin.

Storage:
Store at room temperature (25°C) and protect from light. Store in tight, light-
resistant containers as norepinephrine is readily oxidised. Do not use if
discoloured (e.g. pink, dark yellow, brown) or if there is a precipitate.
Nicardipine
 Clinical Uses

Used to treat high blood pressure and to

control angina (chest pain)
 Mechanism of action
Classification: Calcium-channel Blocker

Mechanism of Action

 Calcium-channel blocker (dihydropyridine); inhibits

transmembrane influx of extracellular calcium ions across
membranes of myocardial cells and vascular smooth muscle
cells without changing serum calcium concentrations; this
inhibits cardiac and vascular smooth muscle contraction,
thereby dilating main coronary and systemic arteries
 Produces vasodilation and decreases peripheral resistance
 DOSAGE
Short-term treatment of hypertension:

Adult: Via slow IV infusion at an initial rate of

5 mg/hr via slow infusion.

Increase infusion rate as necessary, up to max 15

mg/hr. Consider reducing to 3 mg/hr after response
is achieved.
 Administration
IV Incompatibilities: Lactated Ringer solution,
sodium bicarbonate 5%
IV Compatibilities: D5/NS, D5/LR, D5W, NS
IV Preparation:
Dilute ampules before infusion: 25 mg diluted in 240
mL IV fluid (yielding 250 mL of 0.1 mg/mL solution)
Commonly encountered dilution: 10 mg in 90 mL D5W
or PNSS

Premixed infusion solution requires no dilution

Isosorbide Dinitrate
(Isoket)
 CLINICAL USES
 Severe or unstable angina pectoris
 unresponsive left ventricle failure secondary
to acute myocardial infarction;
 to facilitate or prolong revascularization
procedures, and to
 prevent or relieve coronary spasm during
percutaneous transluminal coronary
angioplasty.
 MECHANISM OF ACTION
 Isosorbide dinitrate (ISDN) is an organic nitrate, which is common with
other cardioactive nitrates, is a vasodilator.

 It produces decreased left and right ventricular end- diastolic pressures to

a greater extent than the decrease in systemic arterial pressure, thereby
reducing afterload and especially the preload of the heart.

 It reduces the requirements of the myocardium for oxygen by increasing

venous capacitance, causing a pooling of blood in peripheral veins,
thereby reducing ventricular volume and heart wall distension.
 Dosage
Stock dose: 10 mg per 10 mL (1mg/mL)

Adult IV:

A dose of between 2 mg and 12 mg/hr is usually

satisfactory. However, dosages up to 20 mg/hr
administered should be adjusted to the patient
response.
 Administration
 Isoket is a concentrated solution and must be diluted
prior use.
 The diluted solution should never be injected in the
form of a bolus except via the intracoronary route prior
to balloon inflation.
 Prepared Isoket admixtures should be given by IV
infusion
 During administration the patient's blood pressure
and pulse should be closely monitored.
 Common Pitfalls in Drug Administration

1. Drug computation
2. Titration

Error is an integral part of human life. However, medication errors

can significantly affect patient safety and treatment costs and
result in hazards for patients and their families.

Medication errors can lead to adverse outcomes such as

increased mortality, increased duration of hospitalization, and
increased medical expenses.
DRUG CALCULATIONS
Dopamine mcg/kg/min
Dobutamine mcg/kg/min
Norepinephrine mcg/min
Nicardipine mg/hr
Isoket mg/hr
EXAMPLE #1
Patient Moana has the following vital signs:
BP 180/120 RR 24 cpm
HR 100 bpm

Dr. A wants to start Nicardipine drip on her patient.

“Start Nicardipine drip: 10 mg in 90 mL PNSS to start at
5 cc/hr. Titrate by 3 cc every hour to maintain SBP
130-140 mmHg.”

What is the infusion rate in cc/hr?

Dr. A wants to start Nicardipine drip on his patient.

“Start Nicardipine drip: 10 mg in 90 mL PNSS to

start at 1 mg/hr. Titrate by 0.5 mg/hr every hour
to maintain SBP 130-140 mmHg.”

What is the infusion rate in cc/hr?

 EXAMPLE #2:

Dr. A ordered to start dopamine drip at 5 mcg/kg/min

for patient Jack.
Jack weighs 110 lbs.
Dr. A wants to incorporate 400 mg of Dopamine in 250
mL of D5W.

What is the rate of infusion in mL/hr?

FIRST APPROACH
1. List the given information:

Order: 5 mcg/kg/min
Weight: 110 lbs
Mix: 400 mg/ 250 ml

2. Know the basic conversion.

1 mg= 1000 mcg

1 kg= 2.2 lbs
3. Get the dosage concentration:
How many milligram of Dopamine is in every milliliter of D5W?

400mg
-------------- = 1.6 mg/ml
250 ml

Since the order is in microgram (mcg), convert milligram (mg)

into microgram (mcg):

1.6 mg 1000 mcg

------------- X ------------------ = 1600 mcg/ ml
ml 1 mg
4. Compute the rate of infusion in mL per hour (cc/hr).

5 mcg ml 60 mins 50 kg 15000

-------------- X ------------------ X --------------- X = --------------- =
Kg/min 1600 mcg hour 1600

9.375 mL/hr OR
9.4 mL/hr
 SECOND APPROACH
1. List the given information:

Order: 5 mcg/kg/min
Weight: 110 lbs
Mix: 400 mg/ 250 ml

2. Convert.
1 mg= 1000 mcg
1 kg=2.2 lbs
SECOND APPROACH
3. Get the concentration.

400 mg 1000 mcg ml

-------------- X --------------------- X ---------------- = 26.6 mcg/ ugtts
250 ml 1 mg 60 ugtts

4. Compute the infusion rate in ml per hour.

5 mcg ugtts 50 kg
------------ X -------------- X = 9.39 ugtts/min OR 9.4 ml/hr
Kg/min 26.6 mcg
5. Document your drip.
Use both the micrograms/kilogram/min and
the actual drip rate. Always include the
medication concentration. For our example,
the documentation would read as follows:
Dopamine 400mg/250ml 0.9% Normal Saline
infusing at 5mcg/kg/min with a rate of 9.4
ml/hr.
EXAMPLE #3

You have a patient on a Dobutamine drip

ordered at 10mcg/kg/min. The drip comes as
250mg/100 ml D5W. The patient weighs 50
kgs.

What is the mL/hr?

EXAMPLE #4

Levophed 8 mg in 100 cc D5W to infuse at 6

mcg/min. The patient’s weight is 200 pounds.
How many cc/hour would this be on an
infusion pump?
EXAMPLE #5

Dopamine 400 mg in 250 cc D5W to infuse at

5 mcg/kg/min. The patient’s weight is 200
pounds. How many cc/hour would this be on
an infusion pump?
EXAMPLE #6

Patient Moana is on Isoket drip to control her

chest pain. The concentration is 10 mg in 90
cc PNSS. The order is to begin the infusion at
2 mg/hr.

What is the infusion rate in cc/hr?

You are titrating your Isoket drip and the

current infusion rate is at 30 cc/hr. Determine
the dosage in mg/hr.
EXAMPLE #7
EXAMPLE #8
Thank you!