Drips of the

Stanford Operating Rooms

Brooks H. Rohlen, MD, MS

Stanford University – Department of Anesthesia
March 2009
Adrenergic Receptors
α1 “vasoconstriction”
α2 “analgesia & sedation”
anesthesiologist in a receptor
β1 “ino & chron0”
1 heart, 2 lungs
β2 “vaso & broncho” dilation
1 heart, 2 lungs
DA1 “dilation & diuresis”
dilation arterial of peripherals, renals, mesenterics, and
coronaries (not pulmonary)
 MAP = CO x SVR
CO varies with preload (volume) and cardiac
contractility (β1 “ino & chron0”)

SVR varies with afterload (α1 “vasoconstriction” and β2

“vaso & broncho” dilation)
Understanding Drips Via Receptors
some drips are “pure” and hit a single receptor
 phenylephrine (pure α1)
 fenolDA1pam (pure DA1)

others drips hit multiple receptors

 dopamine (α1 β1 DA1)
 norepinephrine (α1 β1)
 epinephrine (α β)
phenylephrine
“pure α1 squeeze”

 α1 (vasoconstriction)
 0.2-1 mcg/kg/min
 expect a reflexive drop in HR
isoproterenol
“chemical pacemaker”

β1 (ino & chron0)

β2 (vaso & broncho dilation)
1-5 mcg/min
Easily titratable but watch for drops in SVR and MAP.
Often used post-heart transplant to treat denervated
bradycardia (generally just for a few days until HR settles
in to ~100 bpm)
dobutamine
“SVR submarine”

β1 “ino & chron0”

β2 “vaso & broncho” dilation
2-20 mcg/kg/min
Expect a big drop in SVR secondary to the vasodilation
fenoldapam
“fenolDA1pam”

DA1 (dilation & diuresis)

0.05 – 0.2 mcg/kg/min
pure DA1
 arterial dilation vascular smooth muscle relaxation
peripherals
renals
mesentarics
coronaries
 diuresis
fenolDA1pam is evidence we are profit based not evidence based
fenolDA1pam – as evidence
Are we profit based more than evidence based?

fenolDA1pam better than SNP

 not light sensitive
 no toxicity issues
 ½ life is mere minutes
 proven to enhance renal blood flow and GFR
yet we don’t use it often
 because 100 x the cost of SNP
vasopressin (ADH)
“dead gut pressor”

vasopressin receptors (constriction)

0.01-0.04 units/min
no receptors in lungs, kidneys, or coronaries
(brilliant)
there are mesenteric receptors  risk of ischemic
bowel
DDAVP is simply synthetic ADH
 milrinone
“miles and miles of milrinone”

inodilator
 inotropy to heart
 pulmonary vasodilator
phosphodiesterase inhibitor
 thus  breakdown of cAMP leads to  cycling of Ca2+ from SR during
excitation/coupling of heart muscle
Load: 50-75 mcg/kg over 10 minutes
Infuse: 0.375-0.75 mcg/kg/min
long ½ life = difficult to titrate = miles and miles of milrinone
uses: CHF, pulm HTN, RV dysfunction
dopamine
“dopam1ne – the interns drip”

α1 (vasoconstriction)
β1 (ino & chron0)
DA1 (dilation & diuresis)
2-10 mcg/kg/min
“renal dosing dogma” – small doses thought to
produce renal vasodilation due to DA1 receptor
norepinephrine (Levophed)
“leave em dead with ischemic digits”

α1 (vasoconstriction)
β1 (ino & chron0)
0.02 – 0.3 mcg/kg/min
can be seen as an “end of the effort” drip
powerful squeeze leave fingers and toes black/necrotic
from ischemia
Epinephrine
“live people hate it, dead people love it”

small dose (<0.05) β > α

medium doses (0.1-0.2) β = α
large doses (>0.2) β < α
0.02 -0.3 mcg/kg/min
the higher the dose, the more α
nesiritide (BNP)
“the pulmonary dilation that DA1 doesn’t give”

pulmonary dilation and diuresis

load 2 mcg/kg over 1 min.
infuse 0.01 mcg/kg/min
 nitroglycerine (NTG)
“NTG  production of cGMP”

dilates coronaries and veins to decrease preload (volume)

 production of cGMP results in venous > arterial dilation
0.1-1 mcg/kg/min
 nitroprusside (SNP)
“N.O. production”

N.O. dilates arterial vessels to decrease afterload (pressure)

0.1-1 mcg/kg/min
dilates venous > arterial
watch for rebound HTN when discontinued
liver failure pts: liver rhodanase cannot convert cyanide to
thiocyanate thus cyanide toxicity = cellular hypoxia
renal failure pts: b/c they can’t clear thiocyanate they are at
risk for thiocyanate toxicity
 esmolol
“Brevibloc is a damn good name for it”

β1 blocker (blocks ino & chron0)

0.05-0.3 mg/kg/min
a pure β1 blocker so it doesn’t impact the lungs, nor does it
impact afterload (constriction)
“brief” duration of action makes it nicely titratable
there are others...
There are certainly other drips out there with excellent uses,
but this basic outline gives you some of the key drips in
the Stanford Anesthesia bag of tricks.