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Vasoactive Drips: A guide to starting and titrating critical care drips, Adult and Pediatric

3 Contact Hours including 3 Pharmacology Hours
 
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This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Thursday, March 3, 2022
 
Outcomes

Participants will be able to provide a guideline for ordering, dosing, and titrating cardiovascular and critical care medications in the critical care unit.

Objectives

After completing the course, the participant will be able to:

  1. Explain when vasoactive medications are indicated.
  2. Identify the parameters and titration of critical care medications.
  3. Define titration, vasopressor, inotropes, catecholamine, and adrenergic.
  4. Identify vasoactive drugs, infusion rates, and other medications used to treat critically ill patients.
  5. Describe how to calculate and verify drug mixtures every time a critical drug is administered.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.
Last Updated:
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    James Wittenauer(RN, MSN, MPA, RN-BC)

Definitions

The following definitions are used when addressing vasoactive medications:

  • Titration: increasing or decreasing a vasoactive drug infusion for therapeutic effect.
  • Vasopressor: a class of drugs that induce arteriole vasoconstriction and thereby elevate blood pressure.
  • Inotropes: drugs that affect the strength of contraction of the heart muscle (myocardial contractility); negative inotropes decrease cardiac workload and blood pressure, and positive inotropes increase cardiac workload and blood pressure. (Negative inotropes are beta-blockers, diltiazem, and verapamil. Positive inotropes are dopamine, dobutamine, epinephrine, and norepinephrine).
  • Chronotrope: Any medication that affects the heart rate. The chronotrope may include a positive or negative response such as Lopressor or Cardizem for a negative chronotrope or Dobutamine, which can be a positive chronotrope.
  • Catecholamine: any of a class of aromatic amines that includes several neurotransmitters which cause sympathomimetic action (epinephrine, norepinephrine, Dopamine, Dobutamine).
  • Adrenergic: having characteristics of secreting epinephrine or substances with similar activity (epinephrine and norepinephrine).

It should be noted that medications can be classified in multiple classes as chronotropic and/or inotropic.

Introduction

Vasoactive medications are indicated when the Systolic Blood Pressure (SBP) has a decrease of > 30mmHg from the baseline or a Mean Arteriole Pressure (MAP) less than 60-65mmHg and when either condition results in end-organ dysfunction due to hypoperfusion. Additionally, vasoactive medications are used for the management of a hypertensive crisis, flash pulmonary edema, sepsis, shock states, atrial fibrillation with rapid ventricular response, supraventricular tachycardia, heart failure, and hemodynamically unstable patients.

Vasopressors should be infused via central access but can be administered peripherally until central access is obtained. All vasoactive drips can cause severe tissue injury if infiltration occurs. It should also be considered to have arterial line pressure monitoring for patients on vasoactive drips. A physician's order is needed to administer any vasoactive drip, and the order should include parameters to titrate related to heart rate, blood pressure, respiratory rate, and oxygen saturation if indicated. Healthcare providers must know the maximum dose, the minimum dose, the titration parameters, and side effects for all critical care drips and infusions.

Remember that cardiac output is the holy grail of hemodynamics. To maintain blood pressure and heart rate, cardiac output must be sustained. Cardiac output is defined by the stroke volume times the heart rate (SV X HR). The cardiac output is a vital part of oxygen delivery, blood pressure, urine output, and perfusion.

There are many drugs used for hemodynamic instability, cardiogenic shock, and neurogenic shock. Norepinephrine, epinephrine, phenylephrine, vasopressin, dopamine, and dobutamine are a few of the medications used. Volume loss and hypovolemia should be corrected before the administration of any vasopressor. If the fluid status is unknown, then continue close hemodynamic monitoring to determine the efficacy of the vasoactive drip. 1 Vasoactive drips will only temporarily correct hypovolemia, and then the patient will become unstable again until the fluid volume status of the patient is corrected. All critical care drips must be on an infusion pump. All patients on vasoactive medications must be on a continuous heart monitor, along with blood pressure and oxygen saturation monitoring. Emergency resuscitative equipment and medications should always be immediately available to manage any unwanted medication reactions. 2

Vasoactive Drip Calculations

 

Pre-Mixed Dopamine

Here is the basic equation for formulating, mixing, and calculating drip rates. For the purpose of this exercise, a consistent patient weight of 75 kg will be used for all calculations.

The following formula can be used for all critical care medications using only the applicable elements. If the drug ordered is mcg/min, then omit the kg element. 3

Ordered amount of drug x patients weight in kg x 60 minutes/Drug concentration (mg divided by mL) then multiply x 1000 for mcg
= mL/hr

Examples of drug calculations will be shown after medication definitions, dosing, and titration instructions.

References

  1. Greenwood, John. PressorDex. Irving: EMRA, 2013. Print.
  2. Castano, FC. Emergency Medicine. 6th ed. Washington: American College of Emergency Physicians, 2012. Print.
  3. JBF/KRR/AKW Vasoactive drip calculations Retrieved October 4, 2015. Visit Source.
  4. Craig-Brangen, Karen and Day, Mary Patricia. Update: 2017/2018 AHA BLS, ACLS, and PALS guidelines. Nursing2019: February 2019 - Volume 49 - Issue 2 - p 46-49.
  5. Karim, M.I. Khan, M.S. Panhwar, F. Nadeem, D. Carroll, A. Kalra. Cyanide Toxicity at "Safe" Dose of Sodium Nitroprusside Within 24 Hours of Treatment. Visit Source.
  6. Mrad S, El Tawil C, Sukaiti WA, Bou Chebl R, Abou Dagher G, Kazzi Z. Cardiac Arrest Following Liposuction: A Case Report of Lidocaine Toxicity. Oman Med J. 2019;34(4):341–344. doi:10.5001/omj.2019.66