When to add norepinephrine, how much to add, how to titrate it, increase or decrease, what should be the target, what is the dose and how to prepare that solution and then what is there on the infusion pump in ml per hour. I think these might be the question in your mind and I'll be discussing everything over here about visopressors and anotropic agents in this video in a simplified manner. So keep watching this video till the end. Now vasopressors and ionotropic agents they are two different terms. As the name says vasopressor vo means vessel and pressure means the pressure it is created. So it causes all these vasopressor agents causes vasoc constriction whereas ionotropic means means fibers tropic mean increase in efficiency of the myioardium right the fibers of the myioardium. Hence it causes contractility of the heart. So vasopressors causes vasoc constriction whereas inotropic causes cardiac contraction. Now the agents which comes under vopressors are norepinephrine, vasopressin, phenilephrine, epinephrine and dopamine. Whereas on the other side under inotropic agents we have dobutamine, milrenone, isoproenol, epinephrine and dopamine. Now what you can see in this in both sides we have epinephrine and dopamine which is common right which can act as vasopressors and inotropic agent but again depends upon the dosage which we are using right and I'll be talking about that as well. Now a brief about receptors alpha one right just I I know it is boring but yes we have to we need to know right I'll be coming on to the interesting part right very soon. So alpha 1 is there on the blood vessels causing vasoc constriction where norepinephrine very commonly acts with this because the main receptor on which norepinephrine acts is alpha 1 causing vasoc constriction. Beta 1 remember we have one heart. So beta 1 and uh they causes increased contractity and increase of heart rate and very commonly the drug which causes beta 1 action is epinephrine and doutamine. Beta 2 remember we have two lungs right and it acts on the bronus of the lungs causing bronco dilotation and epinephrine let's say it acts on beta2 also it causes bronco dilation then we have v1 receptors which are present on the vessels so vasopressin acting on v1 causing vasoc constriction then we have the d1 receptors which are not commonly used nowadays and we are not using that dose of dopamine right although it causes renal and splanknic vasoddilation Now before jumping onto the each drug we need to have certain rules right when we start when we think about starting these vasopressor agents or entropic agents very first one is always always make sure you have a central line whenever there's acute scenario patient is hypertensive yes as a short-term you can start from a peripheral line but when you see and when you assess yes the requirement is going on a high side always try to secure a central line catheter or central catheter. Right? So that is very important. Secondly, you have to always assess ECG, the map of a patient, urine output of a patient and lactate of a patient. So these four should be always always assessed. Third, never delay the start of visopressor or entropic agent and never be a in a hurry to just stop it, right? just for the sake of it because patient wants or the relative wants or your consultant wants right or you are feeling happy that yes you have titrated. No. Right. So, take time, right? Let the blood pressure stabilize and then titrate or then decrease it. Right? And fourth, you have to have a set goal. Your goal should be to maintain a mean arterial pressure more than equal to 65 mm mercury. So, these goals are very important, right? When we are going with these drugs. Now, coming on to the most interesting part, right, about these drugs. Talking about the first drug which is norepinephrine. Now to prepare that we take two ampules. One has 2 mg. So 2 ampule has 4 mg and we take in 50 ml syringe. Now uh the starting dose of norepinephrine is 0.05 micro g per kg per minute. This seems to be very difficult right microgram per kg per minute and all. So I'll just simplify. If you consider uh starting on a 70 kg uh patient then yes the dose in ml per hour which is there on your infusion pump comes out to be 2.62 ml per hour. So this is what you need to start the patient. So just remember starting dose is 2.5 ml per hour on the infusion pump if you have taken two ampules or of norepinephrine. I'm just simplifying it right and you can uh go up till the maximum is 1 micro g per kg per minute obviously taking into account and titrating right and keeping the map more than equal to 65 mm mercury now comes the point when to add on the next one which is vasopresent if the requirement is more than 2 micro per kg per minute or maybe.3 micro per kg per minute, please add vasopressin. Again, this seems to be diff difficult, right? Microgram per kg per minute. Now, remember on the infusion pump, if the dose increases more than 10 ml per hour or maybe 15 ml per hour, please add vasopressin. Don't keep waiting and keep assessing. Better to add vasopressin. It is always vasopressin is added to decrease the dose of norepinephrine. Right now talking about the second one which is vasopin. It is given at a fixed dose of 03 units per minute. Remember it doesn't have kg. It is not dependent upon the body weight. It is 03 units per minute. And this is prepared by taking two ampules. So one ampule has 20 units per ml. Uh so we take two which is 40 units and we dilute in 40 ml which comes out to be 1 unit per ml. Now again if you start on the infusion pump it will be 1.8 ml per hour. This is what you need to start. The maximum which you can go ahead is 0.04 units per minute which comes out to be 2.4 right. Although uh vis is set as fixed dose you can just go ahead with 1.8 rate right it is not decreased or increased much but yeah if you want to increase you can go ahead till 2.4 for up after that there's no benefit there is more risk and causing eskeeia right so don't increase the vasive resin more than 2.5 ml per hour right so so if you have taken two ampules right that is why I I'm mentioning the concentration as well right third is epinephrine uh 1 ampule has 1 mig and we take four so 4 mg in 50 ml and the Starting dose is 01 microgram per kg per minute and if you calculate again for a 70 kg patient it comes out to be 0 53 ml per hour on the infusion pump. You can take the screenshot of this uh whole chart right once it gets completed so that it becomes easy for you and the maximum dose of epinephrine is 1 microgram per kg per minute as like norepinephrine. Then coming on to the fourth one which is very important is dobutamine. Why I mentioned very important is it has a separate role. It has a role in cardiogenic shock. Whenever the cardiac output is low always always prefer to go with dolbutamine. But the problem with dobutamine is when you start it causes hypotension. In that scenario you can just take assistance of norepinephrine. Once the blood pressure is build up and now you see claic output is low or let's say patient have very low ejection fraction add on give dobutamine to the patient it increases the contractility which is very important. Now uh for dbutamine 1 ampule has 5 ml containing 250 mg and now take this 250 mig in 50 ml. The starting dose is 2 microgram per kg per minute and the maximum is 20 microgram per kg per minute. Right? And and and if you talk about ml per hour, you just start with 1.68. That is the starting dose in ml per hour on the infusion pump. Coming on to the last which is dopamine. Although it is not used commonly nowadays but yes we need to know that also. Uh so one ampule has 5 ml containing 200 mg. So we take 2 amples of dopamine comes out to be 400 mg in 50 ml and the starting dose is 5 micro per kg per minute where it acts on the beta receptors right beta 1 causing the contraction of the heart. More than 10 it acts on alpha causing vasoc constriction and the maximum dose of dopamine is 20 microgram per kg per minute. So uh but also remember about dopamine that it has a very high risk of causing arhythmias. So it is not used nowadays in the clinical practice much. Now to summarize first of all start with norepinephrine very commonly in septic shock and the other shock also you can start that right except for cardiogenic. So start with norepinephrine uh with let's say 2.5 ml per hour if I talk about the infusion pump increase to five and then 10 once it has reached 10 ml per hour right after increasing add on vasopressin which is added in a fixed rose which is 1.8 ml per hour the maximum you can increase is 2.4 for not beyond. Third add epinephrine and the aim should be the target should be to keep MAP more than 65 and also remember to treat the cause right visopressor inotropic are just to support the blood pressure but we have to treat the cause. Now if the the scenario is there's a cardiogenic shock where cardiac output is on lower side or uh you know about the ejection fraction patient ejection fraction is low patient is very cold right and and u in that scenario you have to add doamine now if there's a refractory shock right patient is not improving please consider adding IV hydrocortisone 200 mg per day right that is very very important so this is how we manage and also So in the ICU uh very commonly we use the IVC collapsibility index or we can use PPV pulse pressure variation or you can use the stroke volume variation. So these are the parameters which tells you should you give fluid or not right that the patient is fluid responsive or not which is very important right you can't just keep giving visor or theotropic you have to assess the fluid status as well. So this is all about the phasopressors and the inotropic support right I try to simplify it and do leave you a comment about this video and if you like it please hit the like button and share with your colleagues and obviously do not forget to subscribe this channel and I'll be up uploading and updating more such contents about which is to be used in emergency in the wards in the ICU right in the clinical practice okay bye-bye take