Calculation of infusion

Dose must be counterchecked in mcg/kg/min. Information needed: Dilution, weight, infusion rate.

x mcg a mL
x
Dose (mcg/kg/min) = Concentration (mcg/mL) x Infusion rate (mL/min) weight (kg) = y mL b min
z kg
Drug
Adrenaline
Bradycardia
Hypotension/sho
ck
Dobutamine
Heart
Failure/Shock

Dopamine
Shock

Heart Failure

Dose1,6
IVI 2-10mcg/min Or 0.10.5mcg/kg/min, titrate.
IVI: 0.1-0.5mcg/kg/min, titrate.
IVI 2.5-20mcg/kg/min. Titrate every
few min OR IVI 2.5mcg/kg/min,
double dose every 15 min6
Max: 40mcg/kg/min

IVI 1-5mcg/kg/min, up to
20mcg/kg/min,titrate.
by 1-4mcg/kg/min at 10-30min
interval
Max 50mcg/kg/min.
5-15mcg/kg/min, prefer lower dose.

Noradrenaline
Sepsis
Hypotension/sho
ck

0.01-3mcg/kg/min OR
8-12mcg/min, titrate. Usual MD: 24mcg/min OR
0.1-0.5mcg/kg/min, titrate. (ACLS
2010)

Comment
1> 1 , Low doses = 1+++ ,High doses = 1+++
Continuous infcentral line. *Periextravasation1
Induce arrhythmias and myocardial ischemia, hyperglycemia,
hyperlactanemia2
Reserved for depressed CO in conjunction with severe hypotension. 3
1+++,2++, 1+
2: Vasodilation, systemic and pulmonary vascular resistance. 2
May be preferred in patients with depressed CO, elevatedPCWP, and
increased SVR with mild hypotension.2
Avoid in moderate or severe hypotension (eg, SBP< 80 mm Hg)
because of the peripheral vasodilation.3
Adverse effects: hypotension and tachyarrhythmias 3
1-5 mcg/kg/min: dopaminergic; 5-15mcg/kg/min: 1; >15
mcg/kg/min: 1
May be preferred in patients with depressed CO, normal or
moderately elevated PCWP, and moderate or severe hypotension. 2
>20mcg/kg/min may not have benefit on BP 1
tachyarrhythmia, consider more direct acting vasopressor 1
Causes more tachycardia and may be more arrhythmogenic than
norepinephrine4
1++++, 1++
Induce arrhythmias and myocardial ischemia2
Alkaline inactivate NE (eg. NaHCO3)1
Norepinephrine is more potent than dopamine and may be more
effective at reversing hypotension in patientsw ith septic shock. 4

Clinical application
Septic shock4,5

Cardiogenic shock5,6,7

Drug of choice
Noradrenaline
Adrenaline (added to or substitute NE)
Vasopressin (added to MAP or to NE dose)
Phenylephrine not recommended except:
a) Noradrenaline is associated with serious arrhythmias
b) CO is known to be high and BP persistently low
c) as salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve
MAP target
Dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (eg, patients with
low risk of tachyarrhythmias and absolute or relative bradycardia)
Dobutamine administered or added to vasopressor (if in use) in the presence of
a) Myocardial dysfunction as suggested by elevated cardiac filling pressures and low CO,
b) Ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP
Dobutamine for patient with severe reduction in CO that vital organ perfusion is compromised.
Noradrenaline for severely ill patients with marked hypotension (90mmHg) to raise BP and redistribute

CO from the extremities to the vital organs. 5,6

When SBP <85mmHg, consider non-vasodilating inotrope or vasopressor. 6

Heart Failure7

Dobutamine
Dopamine If UO <20ml/h with no response to doubling of dose of diuretic despite adequate left ventricular

filling pressure (either inferred or measured directly) start IVI dopamine 2.5 g/kg/min. Higher doses are
not recommended to enhance diuresis6
Milrinone
Anaphylactic shock8

First choice: IM Epinephrine (adrenaline) 1:1,000 (1 mg/mL)for mg/kg, to a maximum of 0.5 mg (adult), 0.3
mg (child )
Refractory anaphylaxis: No clear superiority of dopamine, dobutamine, norepinephrine, phenylephrine, or
vasopressin (either added to epinephrine alone, or compared with one another)

Reference:
1. Lexi comp
2. Applied therapeutic
3. Medscape
4. Surviving sepsis
5. Management protocols in ICU. Malaysia. Published 2012
6. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European Heart Journal (2012) 33,
17871847.
7. 2013 ACCF/AHA Guideline for the Management of Heart Failure. Circulation. 2013; 128: e240-e327
8. World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis. WAO Journal, 2010; 4(2):13-37,
February 2011