Dr Kenneth Tan MBBS MMed(Anaes) MRCP(UK) EDIC FCCP Anesthesia and Intensive Care Services Mount Elizabeth Hospital Adrenergic receptor agnoists Phosphodiesterase Inhibitor Milrinone Amrinone Calcium sensitiser Adrenaline Noradernaline Dobutamine Dopamine Levosimendan Vasopressin? Circulation. 2008;118:1047-1056 Circulation. 2008;118:1047-1056 Table. Inotropic and Vasopressor Drug Names, C Dopamine Dobutamine Alpha + Beta 1 +++++ Beta 2 +++ Adrenaline Alpha 1 +++ Beta 1 ++++ Beta 2 ++ Dopaminergic +++++ Alpha 1 +++++ Beta 1 ++++ Beta 2 +++ Noradrenaline Alpha 1 +++++ Beta 1 +++ Beta 2 ++ PDI – e.g. Milrinone Increases intracellular cAMP Increases inotropy, lusitropy and vasodilatation Circulation. 2008;118:1047-1056 Calcium Sensitisers e.g. Levosimendan Sensitises binding of calcium to troponin C Opens ATP dependent potassium channels Leads to increases in inotropy without increasing intracellular calcium and impairment of diastolic relaxation. Vascular vasodilation Vasopressin – Not strictly an inotrope V1a receptors causing vasoconstriction V2 receptors causing water reabsorption Increases vasoconstriction of noradrenaline Inhibits ATP activated potassium channels Reverses adrenergic downregulation Inhibits NO production PubMed Search terms: Cardiogenic shock and Dopamine Cardiogenic shock and Dobutamine Cardiogenic shock and Adrenaline Cardiogenic shock and Noradrenaline Cardiogenic shock and levosimendan Cardiogenic shock and Milrinone 270 Articles 1: Levy B, Perez P, Perny J, Thivilier C, Gerard A. Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. A prospective, randomized pilot study. Crit Care Med. 2010 Oct 28. [Epub ahead of print] PubMed PMID:21037469. 2: De Backer D, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa C, Brasseur A, Defrance P, Gottignies P, Vincent JL; SOAP II Investigators. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010 Mar 4;362(9):779-89. PubMed PMID: 20200382. 3: Obaid L, Johnson ST, Emara M, Bigam DL, Cheung PY. Epinephrine versus dopamine to treat shock in hypoxic newborn pigs resuscitated with 100% oxygen. Shock. 2008 Feb;29(2):262-8. PubMed PMID: 18386393. 232 Articles 1: Levy B, Perez P, Perny J, Thivilier C, Gerard A. Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism,and organ function variables in cardiogenic shock. A prospective, randomizedpilot study. Crit Care Med. 2010 Oct 28. [Epub ahead of print] PubMed PMID: 21037469. 2: De Backer D, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa C, Brasseur A,Defrance P, Gottignies P, Vincent JL; SOAP II Investigators. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010 Mar 4;362(9):779-89. PubMed PMID: 20200382. 263 articles 1: Obaid L, Johnson ST, Emara M, Bigam DL, Cheung PY. Epinephrine versus dopamine to treat shock in hypoxic newborn pigs resuscitated with 100% oxygen. Shock. 2008 Feb;29(2):262-8. PubMed PMID: 18386393. 2: De Backer D, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa C, Brasseur A, Defrance P, Gottignies P, Vincent JL; SOAP II Investigators. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010 Mar 4;362(9):779-89. PubMed PMID: 20200382. 3: Levy B, Perez P, Perny J, Thivilier C, Gerard A. Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. A prospective, randomized pilot study. Crit Care Med. 2010 Oct 28. [Epub ahead of print] PubMed PMID: 21037469. 4: Bagwell EE, Daniell HB. Comparative effects of dopamine and norepinephrine on myocardial function and metabolism during experimental cardiogenic shock. J Pharmacol Exp Ther. 1970 Jun;173(2):357-63. PubMed PMID: 5434019. 147 Articles 1: Levy B, Perez P, Perny J, Thivilier C, Gerard A. Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. A prospective, randomized pilot study. Crit Care Med. 2010 Oct 28. [Epub ahead of print] PubMed PMID: 21037469. 2: Samimi-Fard S, García-González MJ, Domínguez-Rodríguez A, Abreu-González P. Effects of levosimendan versus dobutamine on long-term survival of patients with cardiogenic shock after primary coronary angioplasty. Int J Cardiol. 2008 Jul 4;127(2):284-7. Epub 2007 Jul 23. PubMed PMID: 17643519. 63 articles 1: Samimi-Fard S, García-González MJ, Domínguez-Rodríguez A, Abreu-González P. Effects of levosimendan versus dobutamine on long-term survival of patients with cardiogenic shock after primary coronary angioplasty. Int J Cardiol. 2008 Jul 4;127(2):284-7. Epub 2007 Jul 23. PubMed PMID: 17643519. 2: De Luca L, Colucci WS, Nieminen MS, Massie BM, Gheorghiade M. Evidence-based use of levosimendan in different clinical settings. Eur Heart J. 2006 Aug;27(16):1908-20. Epub 2006 Apr 27. Review. PubMed PMID: 16682381. 24 Articles 1: Beute J. Levosimendan is superior to enoximone in refractory cardiogenic shock complicating acute myocardial infarction. Crit Care Med. 2008 Aug(36):2257-2286 2: Samimi-Fard S, García-González MJ, Domínguez-Rodríguez A, Abreu-González P. Effects of levosimendan versus dobutamine on long-term survival of patients with cardiogenic shock after primary coronary angioplasty. Int J Cardiol. 2008 Jul 4;127(2):284-7. Epub 2007 Jul 23. PubMed PMID: 17643519. No good evidence for any inotrope or combination. Physiologic principles guide management. Witchcraft ☺ Questions?