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2012 SCC 新建議 for Septic shock
- 強烈建議 Norepinephrine 為升壓劑首選
- Vasopressin 0.03 U/min 為替代藥物或可合併使用 (2A)
- 須加上第二種升壓劑時, 可選擇 Epinephrine (Weak recommended) (2B)
α-adrenergic receptors
β-adrenergic receptors (β1 > β2), leading to inotropic stimulation of the heart and coronary artery vasodilation
- 沒有 Beta 2 effect : 不會擴張骨骼肌血管
- 只有 alpha 1 effect : 血管收縮, SBP, DBP 都上升
- 弱 Beta 1 effect : 因為相較於 alpha1 太弱, 所以會 Baro reflex
4 Amp in 250cc D5W
16 mg / 250 ml = 64 mcg/ml
Start : 2 μg/min (1.8 ml/hr)
Range 0-20 μg/min (18.75 ml/hr)
【Central access】4支泡250
【Dilution/Conc】16 mg norepinephrine in D5W 234 mL, concentration 64 mcg/mL
【Rate】Start at 2 mcg/min, range 0-20 mcg/min (Dose above recommended range is justified by clinical judgement)
【Titration/Taper】
# Titration：check BP Q5-15 min and increase by 2-5 mcg/min (1.9-4.7 mL/hr)
# Taper (by clinical judgement)：check BP Q15-30min and decrease by 1-2 mcg/min (0.9-1.9 mL/hr)
【Goal】Mean arterial pressure ≧ 65 mmHg or Systolic BP≧ 90 mmHg
【Peripheral access】2支泡500
【Dilution/Conc】8 mg norepinephrine in D5W 492 mL, concentration 16 mcg/mL
【Rate】Start at 2 mcg/min, range 0-20 mcg/min
【Titration/Taper】
# Titration：check BP Q5-15 min and increase by 2-5 mcg/min (7.5-18.7 mL/hr)
# Taper (by clinical judgement)：check BP Q15-30min and decrease by 1-2 mcg/min (3.7-7.5 mL/hr)
【Goal】Mean arterial pressure ≧ 65 mmHg or Systolic BP≧ 90 mmHg
Renal perfusion 會變差
Levophed 不能用於血容量減少的低血壓病人 !
除非在血容量補充治療完成之前的緊急維持冠狀動脈及腦動脈灌流
若連續使用 Levophed 維持血壓卻沒有補充血容量：
- 嚴重性末稍及內臟血管收縮
- 腎灌流及尿排出量減少
- 雖然血壓正常但全身性血流不好
- 組織缺氧及乳酸中毒
角色下降, 但以下情形還是會考慮 dopamine：
【1】Severe bradycardia
【2】Shock in pediatric population
**
At intermediate doses (5 - 10 micrograms/kg/min) : dopamine increases renal blood flow, heart rate, cardiac contractility, and cardiac output.
At high doses (>10 micrograms/kg/min), the α-adrenergic effects of dopamine dominate, leading to vasoconstriction and increased blood pressure.
Low-dose (1 - 5 micrograms/kg/min) dopamine is no longer recommended for renal protection due to lack of patient outcome evidence.
Only in highly selected patients (i.e., patients with low risk of tachyarrhythmias and absolute or relative bradycardia)
Treatment of symptomatic bradycardia that is unresponsive to atropine.
**
使用時機：
急性心肌不全, 心肌衰竭, 心臟性休克
腎衰竭, 手術中維持腎之正常功能及正常尿量
手術中休克, 手術中提高血壓, 維持血液循環之安定
收縮性血壓＜90 mmHg 而排除低血容
有症狀的心博過慢病患並有低血壓
復甦後並有低血壓的病患
Dopamine : 2 - 20 mcg/kg/min
- Beta effect : 5 mcg/kg/min (Run 10 ml/hr)
- Alpha + Beta effect : 10 mcg/kg/min (Run 20 ml/hr)
- MAX : 20 mcg/kg/min (Run 40 ml/hr)
1 amp 200 mg
4 amp in D5W 500ml
800/500 = 1.6 mg/cc = 1600 mcg/cc
Beta effect : 5 mcg/kg/min = 300 mcg/kg/hr = 18000 mcg/ 60kg / hr
18000 / 1600 = 11 = 10 cc/hr
5 micrograms/kg/min = Run 10 cc/hr
開始滴之後效果大概要 10mins
10mins 後沒效可以再往上調
【Central access】
【Dilution/Conc】800 mg dopamine in D5W/NS 230 mL, concentration 3.2 mg/mL
【Rate】Start at 5 mcg/kg/min, range 0-20 mcg/kg/min
【Titration/Taper】
# Titration：check BP Q5-15 min and increase by 1-5 mcg/kg/min
# Taper (by clinical judgement)：check BP Q15-30 min and decrease by 1-2 mcg/kg/min
【Goal】Mean arterial pressure ≧ 65 mmHg or Systolic BP ≧ 90 mmHg
【Peripheral access】
【Dilution/Conc】400 mg dopamine in D5W/NS 490 mL, concentration 0.8 mg/mL
【Rate】Start at 5 mcg/kg/min, range 0-10 mcg/kg/min
【Titration/Taper】
# Titration：check BP Q5-15 min and increase by 1-5 mcg/kg/min
# Taper (by clinical judgement)：check BP Q15-30 min and decrease by 1-2 mcg/kg/min
【Goal】Mean arterial pressure ≧ 65 mmHg or Systolic BP ≧ 90 mmHg
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