Kelvin ,Chin Woon ,Juhainah ,Yushia ,Liana

An agent which alters the force of muscular contraction.

Inotropes are used in the management of various cardiovascular conditions. Change in contractility of the heart is called inotropic effect

2 types of inotrope agents.

Positive Negative

Positive Inotrope Agents

Increases the strength of muscular contractions.

Negative Inotrope Agents

Decreases the strength of muscular contractions.

Increase myocardial contractility Support cardiac function in conditions such as:

Decompensated Congestive Heart Failure
Cardiogenic Shock Septic Shock

Myocardial Infarction (MI)

Cardiomyopathy

Digoxin Dopamine Epinephrine Norepinephrine

Decrease myocardial contractility Used in decreasing cardiac workload for angina. May precipitate or exacerbate heart failure.

 Flecainide Beta Blockers Calcium Channel blockers Quinidine

Haemodynamic impairment with low cardiac output. Critical conditions caused by abnormal haemodynamics and including of the following: Severe exercise limitation Diuretic resistant fluid overload Shown by Kidney dysfunction abnormal lab Liver dysfunction results

Inotropic therapy is occasionally required on a truly emergent basis for patients with evidence of critical hypoperfusion, such as lactic acidosis. Such patients require immediate institution of inotropic therapy until the cause of shock is determined and definitive therapy implemented.

The two types of shock are - Hypovolemic shock - Cardiogenic shock

Intravascular volume decreased 15% (due to burn) Blood Pressure decreased (Blood returning to heart decreased) Ventricular filling decreased Loss of blood volume (haemorrhage) Loss of body fluid (severe vomiting/ diarrhoea/ continuous nasogastric suctioning) Renal looses fluid (diuretics/ endocrine disorders)

Cardiac output compromised Inadequate tissue perfusion Myocardial infarction (most common cause) Progressive depletion of oxygen causes myocardial ischemia

Poor heart contractility may be caused by:1. Cardiac arrest 2. Dysarythmias 3. Cardiomyopathies 4. Cardiac surgery (due to myocardial damage) 5. Drugs affecting muscle contractility (Digoxin) 6. Cardiac temponade

Digoxin

Blocks an enzyme called Sodium Potassium ATPase, which controls the amount of sodium and potassium that enters a cell

Causing an increase in the amount of sodium and potassium that enters a cell
Heart contracts more forcefully with each heartbeat

Thus, Slowing down the heart rate

Allowing more blood volume to be pumped into the body

Nausea and Vomitting Headache Visual Disturbances Blurring Vision Dysrhythmias AV block

MOA is depending on the dose Low doses Stimulates dopaminergic receptors, especially in the kidneys Leading to vasodilatation and an increased blood flow through the kidneys Treating the cardio and hypo shock

High doses Stimulates beta1-adrenegic receptors Heart to beat more forcefully Increasing co Stimulate alpha adrenergic receptors, vasoconstriction and raising blood pressure

Chest pain Palpitations Headache Anxiety Oliguria Dyspnea Ventricular arrhythmia

Stimulates both alpha- and beta- adrenergic receptors Immediately after injection, BP rises due to stimulation of alpha1 receptors Beta2 receptors in the bronchi opens the airway and relieves SOB CO increases due to stimulation of beta1 receptors

Nervousness Tachycardia Dizziness Headache Sting/burning at the site of application

Acts directly on alpha-adrenegic receptors in vascular smooth muscle to immediately raise blood pressure It also stimulates beta1 receptors in the heart Thus producing a positive inotropic response increase CO Primary indications acute shock or cardiac arrest Vasopressor of choice for septic shock

Bradyarrhythmia Hypertension Extravasation injury Nausea and vomitting Confusion Anxiety Cardiac arrest

Assessment Understand the reason the drug has been prescribed Complete health history including cardiovascular (including HTN, MI), neurologic ( including CVA or head injury ), burns, endocrine, hepatic or renal disease Baseline weight and vital signs, level of consciousness, breath sounds, urinary and cardiac output Evaluate appropriate lab findings

Assessment throughout administration Assess for desired therapeutic effects dependent on the reason for the drug ( e.g. BP, pulse, CO) Continue frequent and careful monitoring of vital signs and urinary and cardiac output as appropriate Assess for and promptly report adverse effects : tachycardia Hypotension Dysrhythmias Decreasing LOC Allergic Reactions

Ensuring therapeutic effects

Continue frequent assessments as above the therapeutic effects dependent on the reason the drug therapy is given

Rationale
Pulse, BP, RR should be within normal limits or within parameters set by the health care provider, ABGs and/or pulse oximetry are within acceptable parameters. Urine output has increased.

Provide supportive nursing measure; e.g. moistening lips if patient is intubated, explanations for all procedures and frequent orientations

Decrease patient anxiety and supplement therapeutic drug effects to optimized outcome.

Minimizing A.E.
Monitor signs of fluid volume excess. Continue frequent cardiac monitoring

Rationale
Because of the critical condition of the patient in shock, a delicate balance between fluid volume excess and deficit exists. Frequent assessment must be made to detect and avoid A.E. External and invasive monitoring devices will detect early signs of A.E.

Weigh patient daily and report weight gain Daily weight is an accurate measure of or loss of 1 kg or more in 24 hour period. fluid status and takes into account intake, output and insensible losses. Weight gain or edema may signal excessive fluid volume.

Patient education
Advise patient to avoid activities requiring mental alertness or coordination until drug effects are realized.

Rationale
This drug may cause blurred vision.

Advise patient to take high fiber food and increase water intake

This drug may cause constipation

Advise patient to wear sunglasses and avoid bright light.

Ophthalmic forms can cause photophobia.

Patient education
Instruct patient to use caution with activities leading to an increased core temperature(dehydration, strenuous exercise)

Rationale
This drug impairs heat regulation.

Instruct patient to inform for difficulty in breathing. Instruct patient on proper instillation and administration techniques for ophthalmic product.

This drug may cause respiratory depression.

To reach therapeutic drug effect.

Singhal, M. (2008, September 10). Inotropes. Retrieved from http://www.scribd.com/doc/5706202/INOTROPES Heart Fail Reviews. (2009, October 30). Indications for inotropic therapy. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2772951/table/Tab1 / Texas Heart Institute. (n.d.). Retrieved from http://www.texasheartinstitute.org/HIC/Topics/Meds/inotropic.cf m Lakey, S. (n.d.). Retrieved from http://congestive-heartfailure.emedtv.com/digoxin/digoxin-mechanism-of-action.html Stevenson, L. W. (n.d.). Retrieved from http://circ.ahajournals.org/content/108/3/367.full Adams, M. P., Holland, L. N., & Urban , C. Q. (2011).Pharmacology for nurses. (3rd ed.). Pearson Education International

a) b) c) d)

Digoxin Dopamine Beta Blockers Epinephrine

a) Nephropathy b) Septic Shock c) Myocardial Infarction (MI) d) Cardiomyopathy

a) b) c) d)

Ineffective tissue perfusion Deficient knowledge Risk for injury Sleeping disturbances

a) b) c)

d)

Dysarythmias Cardiomyopathies Hypothyroidism Cardiac surgery

True or False

True or False?

a)
b) c)

d)

Sting/burning at the site of application Diarrhea Constipation Hypotension

a)
b) c)

d)

Chest pain Palpitations Headache Diarrhea

Hypovolemic shock Loss of blood volume (haemorrhage) Loss of body fluid

Cardiogenic shock Cardiac output compromised Inadequate tissue perfusion

Positive Digoxin Dopamine Epinephrine Norepinephrine

Negative Flecainide Beta Blockers Calcium Channel blockers Quinidine