Inotropes discontinuation

Vasopressin levels are increased during hypotension to maintain blood pressure by vasoconstriction. However, there is a vasopressin deficiency in septic shock. Low doses of vasopressin increase MAP, leading to the discontinuation of vasopressors. However, routine use of vasopressin is not recommended because of lack of evidence of efficacy. Vasopressin is a direct vasoconstrictor without inotropic or chronotropic effects and may result in decreased cardiac output and hepatosplanchnic flow. Vasopressin use may be considered in patients with refractory shock despite adequate fluid resuscitation and high-dose vasopressors.24,27-28... 

FIGURE 8-2. General treatment algorithm for acute decompensated heart failure (ADHF) based on clinical presentation. IV vasodilators that may be used include nitroglycerin, nesiritide, or nitroprusside. Metolazone or spironolactone may be added if the patient fails to respond to loop diuretics and a second diuretic is required. IV inotropes that may be used include dobutamine or milrinone. (D/C, discontinue HF, heart failure SBP, systolic blood pressure.) (Reprinted and adapted from J Cardiac Fail, Vol 12, pages el-el 22, copyright 2006, with permission from Elsevier.)... 

As propafenone exerts both beta blockade and a (dose-related) negative inotropic effect on cardiac muscle, fully compensate patients with CHF before receiving propafenone. If CHF worsens, discontinue propafenone unless CHF is due to the cardiac arrhythmia and, if indicated, restart at a lower dosage only after adequate cardiac compensation has been established. 

CHF Do not administer itraconazole for the treatment of onychomycosis in patients with evidence of ventricular dysfunction, such as CHF or a history of CHF. Discontinue if signs and symptoms of CHF occur during treatment. If signs and symptoms of CHF occur during treatment, reassess the continued use of itraconazole. When itraconazole was administered IV to dogs and healthy human volunteers, negative inotropic effects were seen. 

In most cases, fluorouracil-induced dysrhythmias were treatable and the ischemic-like symptoms and electrocardiographic changes disappeared if the infusion was discontinued or responded to nitrates, allowing the infusion to continue. The abnormalities of segmental and global ventricular function reverted to normal within days to weeks of withdrawal. In some patients intravenous inotropic and vasodilator support was needed during the initial period (14—16,19). 

In some patients, dobutamine (or milrinone) dose reduction or discontinuation results in acute decompensation, and these patients then may require placement of an indwelling intravenous catheter for continuous therapy. This approach may be used to bridge patients awaiting cardiac transplantation and also may be used to facilitate the discharge of patients who are not transplant candidates but who cannot be weaned from inotrope therapy. The use of continuous... 

Therapy with vasopressors and inotropes is continued until the myocardial depression and vascular hyporesponsive-ness of septic shock improve, usually measured in hours to days. Discontinuation of vasopressor or inotropic therapy should be executed slowly therapy should be "weaned" to avoid a precipitous worsening in regional and systemic hemodynamics. 

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