Diambil dari : http://www.jurnalmedika.com/edisi-tahun-2012/edisi-no-12-vol-xxxvii-2012/501-kegiatan/1099-dobutamin-untuk-stabilisasi-dan-koreksi-kontraksi-jantung-.

Dobutamin untuk Stabilisasi dan Koreksi Kontraksi Jantung 

Syok dalam Kamus Kedokteran Dorland adalah gangguan keseimbangan fisik atau mental yang timbul mendadak. Atau dapat juga diartikan sebagai gangguan metabolik dan hemo-dinamik berat yang ditandai dengan kegagalan sistem sirkulasi untuk mempertahankan per-fusi organ vital yang adekuat. Keadaan ini disebabkan oleh volume darah yang tidak adekuat (syok hipovolemik); fungsi jantung tidak adekuat (syok kardiogenik), atau tonus vasomotor tidak adekuat (syok neurogenik dan syok septik). Perubahan gaya hidup masyarakat dan semakin maraknya makanan yang tidak sehat saat ini menjadikan kasus syok kardiogenik semakin meningkat. Di Amerika,  angka kejadian syok termasuk syok kardiogenik di unit-unit emergensi meningkat dari 17% pada 1998 menjadi 22% pada 2002. Padahal, dampak terjadinya syok kardiogenik ini dapat menyebabkan serangan jantung (cardiac arrest) atau kerusakan organ. Hal ini dapat mengakibatkan kematian dengan cepat bila tidak segera dilakukan tindakan medis karena gejalanya bisa memburuk dengan cepat. Oleh karena itu, stabilisasi koreksi bagi penderita syok kardiogenik sangat diperlukan agar tidak sampai terjadi kematian mendadak.

Syok kardiogenik terjadi apabila terdapat kegagalan primer jantung dalam memompa, seperti pada infark miokard atau kardiomiopati berat. Syok ini ditandai oleh gangguan fungsi ventrikel, yang mengakibatkan gangguan berat pada perfusi jaringan. Masalah yang terjadi disini adalah kurangnya kemampuan jantung untuk berkontraksi. Atau kondisi curah jantung yang menjadi berkurang atau berhenti sama sekali untuk memenuhi kebutuhan metabolisme. Sehingga kondisi jaringan tubuh menjadi kekurangan oksigen (hypoxia). Hal inilah nantinya yang mengakibatkan munculnya serangan jantung.

Gejala syok kardiogenik dapat dikenali melalui tanda-tanda seperti pernapasan menjadi cepat, sesak napas pada saat istirahat, detak jantung tiba-tiba cepat (takikardia), kebingungan, kehilangan kesadaran atau pingsan, denyut nadi lemah,  berkeringat, kulit pucat, dan tangan atau kaki dingin. Alat-alat canggih untuk memastikan lebih jauh pasien menderita penyakit ini biasanya menggunakan  electrocardiogram (ECG), sonogram, scan jantung, kateterisasi jantung, atau roentgen dada.

Pengobatan syok kardiogenik  berfokus pada perbaikan kerusakan pada otot jantung dan organ lain yang disebabkan oleh kekurangan oksigen. Oleh karena itu, diperlukan obat-obat inotropik positif untuk mengatasi gangguan dinamika aliran darah di dalam tubuh akibat syok dengan meningkatkan kontraksi otot jantung agar oksigen dapat disalurkan ke jaringan tubuh dengan lancar. Melalui kesempatan acara Weekend Course on Cardiology (WECOC) yang diselenggarakan oleh para pakar jantung pada akhir Oktober lalu, PT Pharos dengan bangga memperkenalkan obat inotropik positif yaitu dobutamin. Produk yang diberi nama Cardiotoneâ ini mengandung 50 mg/ml dobutamin. Obat ini lebih menonjol dalam hal me-ningkatkan kontraktilitas otot jantung dari pada meningkatkan frekuensi denyut jantung.

Secara kimia, dobutamin mirip dengan dopamin, tetapi mempunyai gugus aromatik sebagai pengganti gugus amino. Dobutamin merupakan sediaan agonis beta-adrenergik yang bersifat inotropik, signifikan memperbaiki fungsi jantung, mengoptimalkan cardiac output, serta meningkatkan konsumsi oksigen pada miokard. Target obat ini adalah mencapai saturasi oksigen di vena sebesar 70%.

Cara pemakaian obat ini yaitu dengan mengencerkannya ke dalam konsentrat infus dengan larutan NaCl 0,9% atau larutan glukosa 5%. Penyimpanan dobutamin pada suhu ruangan di bawah 25oC dan terlindung cahaya. Apabila disimpan pada suhu kamar, larutan infus dapat digunakan selama 12 jam dan apabila disimpan di refrigerator, larutan infus dapat digunakan selama 24 jam. Dosis yang diberikan disesuaikan dengan kondisi penderita sesuai dengan kecepatan jantung, ritme, tekanan darah dan diuresis.

Dengan demikian, dapat disimpulkan bahwa langkah yang dilakukan untuk menanggulangi syok adalah dengan mengenali gejalanya terlebih dahulu karena tidak ada tes laboratorium yang dapat mendeteksi terjadinya syok dengan segera. Diagnosis dibuat berdasarkan pemahaman klinik berupa tidak adekuatnya perfusi organ. Langkah selanjutnya yaitu dengan memberikan terapi secara tepat. Misalnya, dalam manajemen terapi pada beberapa sindrom kardiovaskuler yang berkaitan dengan syok dapat digunakan dobutamin seperti yang terdapat dalam Cardiotoneâ.  (Risky)

Diambil dari: cardiologyupdateunand.com/tag/dobutamine/

Dobutamine Stress Echocardiography12/12/2011

Dobutamine Stress EchocardiographyIndri Putri Festari, Bobby Arfhan Anwar

 

 

Dobutamin merupakan suatu stimulator beta reseptor terutama beta 1 di jantung, ia mempunyai efek sebagai intropik, kronotropik dan dromotropik positif. Efek intropik dan kronotropik dari dobutamin menginduksi iskemia miokard pada jantung yang memiliki stenosis signifikan pada arteri koronernya. Waktu paruh dobutamin adalah 2 menit.

Kebanyakan protokol dobutamin stress ekokardiografi menggunakan dosis awal 5 mikrogram/kg/menit dan dinaikkan hingga 40-50 mikrogram/kg/menit dan pemberian atropine 0,25 sampai 1 mg di akhir test atau beta bloker, seperti esmolol. Stress ekokardiografi ini bermanfaat untuk menilai iskemia miokard yang diinduksi stress dan mendeteksi viabilitas miokardial.

Oksigen dan metabolit disuplai ke miokardium melalui arteri koroner. Aliran darah koroner yang berkurang menyebabkan iskemia miokard akibat deprivasi metabolit. Dalam keadaan istirahat, aliran koroner dapat tercukupi sesuai kebutuhan basal, kecuali jika terjadi stenosis. Dalam keadaan normal, saat terjadi stress, maka aliran koroner akan meningkat sesuai dengan kebutuhan oksigennya. Lebih dari 70%  stenosis korner berhubungan dengan berkurangnya kemampuan aliran maksimal koroner, yang kemudian memicu terjadinya kaskade iskemia. Kaskade iskemia dimulai dengan heterogenisitas perfusi, perubahan metabolism, selanjutnya terjadi gangguan diastolik, disinergi sistolik, perubahan EKG dan munculnya angina pectoris.

Daerah miokard yang mengalami asinergi tidak segera mengalami kerusakan ireversibel atau sikatriks. Oklusi arteri koroner menyebabkan disfungsi miokard,  reperfusi yang bertahap akan mengembalikan fungsi miokard ketahap yang lebih baik dalam kurun waktu tertentu. Fenomena ini disebut “stunned miokardium”.  Jika aliran darah koroner diperbaiki, maka miokardium yang mengalami iskemia kronik akan memiliki kemampuan untuk memperbaiki kontraksinya, ini disebut ‘hibernating myocardium’. Stunning dan hibernating miokard memiliki kemampuan inotropik, yang dapat distimulasi oleh dobutamin, hal ini ditunjukkan oleh gerakan dinding yang lebih baik pada ekokardiogram.

Stess test ekokardiografi dihentikan jika sudah ditemukan endpoint, yaitu ditemukannya gerakan dinding jantung yang abnormal lebih dari 1 segmen, meningkatnya volume akhir sistolik, atau tercapainya denyut jantung maksimal yaitu ( 220-umur)*85%. Selama test, fungsi ventrikel kiri baik regional maupun global dimonitor dengan ekokardiografi, frekuensi nadi dan irama dinilai dengan EKG kontinu dan setiap 3 menit dilakukan pengukuran tekanan darah dan EKG 12-lead.

Stress test ini dilakukan untuk menilai iskemia miokard, bukan untuk membuktikan efek obat antiiskemik. Untuk menilai stress ekokardiografi ini, dinilai 16 segmen ventrikel menggunakan sistem skor. Skor 1 adalah normokinesia, 2 adalah hipokinesia, 3 yaitu akinesia, dan 4 diskinesia.. Abnormalitas gerakan ventrikel ditegakkan jika ditemukan peningkatan skor >1 pada >1 segmen sebagai marker iskemia. Dan dikatan perbaikan jika kenaikan skor >1 pada >1 segmen dengan dobutamin dosis rendah, sebagai biomarker viability miokardium pada abnormalitas yang ditemukan pada saat istirahat

Dobutamin stress echo lebih efisien mendeteksi stenosis arteri koroner daripada exercise ECG dan sebanding dengan skintigrafi perfusi miokard. Dibandingakan dengan angiografi koroner, sensitivitas, spesivisitas, dan akuasi stress echo 72-86%, 77-95%, dan 76-89%. Semakin rendah dosis Dobutamin yang diberikan, semakin rendah tingkat akurasi diagnostiknya. Sensitivitas lebih baik pada stenosis multi-vesel dibandingkan single-vessel dan lebih tinggi pada 70% stenosis dibandingkan 50% stenosis. Sensitivitas maksimum ditemukan pada daerah iskemik yang diperdarahi oleh arteri koroner anterior desending. Stress echo juga mampu menilai viabilitas miokard dengan sensitivitas dan spesifisitas 80 % dan 90%.

Penggunaan strees echo setelah intervensi koroner masih terbatas. Setelah angioplasty coroner yang berhasil, perbaikan gerakan dinding ventrikel dapat dinilai, dan stress echo dapat digunakan pada keadaan restenosis setelah PCI, meskipun tidak dapat membedakan restenosis atau lesi di pembuluh koroner baru.

Pre-operative stress echo merupakan alat diagnostik, terutama pada pasien yang tidak dapat melakukan exercise test, pasien yang memiliki abnormalitas pada dinding ventrikelnya memiliki resiko kardiovaskular peri-operative yang lebih tinggi.

Dobutamin stress echo memiliki beberapa komplikasi yang serius.

http://cardiologyupdateunand.files.wordpress.com/2011/12/dobu-echo-2.jpg

Diambil dari: http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=402f24d2-5e67-4dd6-99c6-84bb7c1c29e7

DOBUTAMINE- dobutamine hydrochloride injection  Bedford Laboratories

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DOBUTamine Injection USP Rx ONLY

DESCRIPTIONDobutamine Injection USP is (±)-4-[2-[[3-(p-Hydroxyphenyl)-1-methylpropyl]amino]ethyl]-pyrocatechol hydrochloride. It is a synthetic catecholamine.

Molecular Formula: C18H23NO3•HCl

Molecular Weight: 337.84

The clinical formulation is supplied in a sterile form for intravenous use only. Each mL contains: dobutamine hydrochloride, equivalent to 12.5 mg (41.5 µmol) dobutamine; sodium bisulfite 0.28 mg (added during manufacture), and water for injection, q.s. Hydrochloric acid and/or sodium hydroxide may have been added during manufacture to adjust the pH (2.5 to 5.5).

CLINICAL PHARMACOLOGYDobutamine is a direct-acting inotropic agent whose primary activity results from stimulation of the ß receptors of the heart while producing comparatively mild chronotropic, hypertensive, arrhythmogenic, and vasodilative effects. It does not cause the release of endogenous norepinephrine, as does dopamine. In animal studies, dobutamine produces less increase in heart rate and less decrease in peripheral vascular resistance for a given inotropic effect than does isoproterenol.

In patients with depressed cardiac function, both dobutamine and isoproterenol increase the cardiac output to a similar degree. In the case of dobutamine, this increase is usually not accompanied by marked increases in heart rate (although tachycardia is occasionally observed), and the cardiac stroke volume is usually increased. In contrast, isoproterenol

increases the cardiac index primarily by increasing the heart rate while stroke volume changes little or declines.

Facilitation of atrioventricular conduction has been observed in human electrophysiologic studies and in patients with atrial fibrillation.

Systemic vascular resistance is usually decreased with administration of dobutamine. Occasionally, minimum vasoconstriction has been observed.

Most clinical experience with dobutamine is short-term–not more than several hours in duration. In the limited number of patients who were studied for 24, 48, and 72 hours, a persistent increase in cardiac output occurred in some, whereas output returned toward baseline values in others.

The onset of action of dobutamine is within 1 to 2 minutes; however, as much as 10 minutes may be required to obtain the peak effect of a particular infusion rate.

The plasma half-life of dobutamine in humans is 2 minutes. The principal routes of metabolism are methylation of the catechol and conjugation. In human urine, the major excretion products are the conjugates of dobutamine and 3-O-methyl dobutamine. The 3-O-methyl derivative of dobutamine is inactive.

Alteration of synaptic concentrations of catecholamines with either reserpine or tricyclic antidepressants does not alter the actions of dobutamine in animals, which indicates that the actions of dobutamine are not dependent on presynaptic mechanisms.

The effective infusion rate of dobutamine varies widely from patient to patient, and titration is always necessary (see DOSAGE AND ADMINISTRATION). At least in pediatric patients, dobutamine-induced increases in cardiac output and systemic pressure are generally seen, in any given patient, at lower infusion rates than those that cause substantial tachycardia (see PRECAUTIONS, Pediatric Use).

INDICATIONS AND USAGEDobutamine is indicated when parenteral therapy is necessary for inotropic support in the short-term treatment of adults with cardiac decompensation due to depressed contractility resulting either from organic heart disease or from cardiac surgical procedures. Experience with intravenous dobutamine in controlled trials does not extend beyond 48 hours of repeated boluses and/or continuous infusions.

Whether given orally, continuously intravenously, or intermittently intravenously, neither dobutamine nor any other cyclic-AMP-dependent inotrope has been shown in controlled trials to be safe or effective in the long-term treatment of congestive heart failure. In controlled trials of chronic oral therapy with various such agents, symptoms were not consistently alleviated, and the cyclic-AMP-dependent inotropes were consistently associated with increased risk of hospitalization and death. Patients with NYHA Class IV symptoms appeared to be at particular risk.

CONTRAINDICATIONSDobutamine is contraindicated in patients with idiopathic hypertrophic subaortic stenosis and in patients who have shown previous manifestations of hypersensitivity to dobutamine.

WARNINGS1.

Increase in Heart Rate or Blood PressureDobutamine may cause a marked increase in heart rate or blood pressure, especially systolic pressure. Approximately 10% of adult patients in clinical studies have had rate increases of 30 beats/minute or more, and about 7.5% have had a 50 mm Hg or greater increase in systolic pressure. Usually, reduction of dosage promptly reverses these effects. Because dobutamine facilitates atrioventricular conduction, patients with atrial fibrillation are at risk of developing rapid ventricular response. In patients who have atrial fibrillation with rapid ventricular response, a digitalis preparation should be used prior to institution of therapy with dobutamine. Patients with preexisting hypertension appear to face an increased risk of developing an exaggerated pressor response.

2.

Ectopic ActivityDobutamine may precipitate or exacerbate ventricular ectopic activity, but it rarely has caused ventricular tachycardia.

3.

HypersensitivityReactions suggestive of hypersensitivity associated with administration of dobutamine including skin rash, fever, eosinophilia, and bronchospasm, have been reported occasionally.

4.

Dobutamine contains sodium bisulfite, a sulfite that may cause allergic-type reactions, including anaphylactic symptoms and life-threatening or less severe asthmatic episodes, in certain susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown and probably low. Sulfite sensitivity is seen more frequently in asthmatic than in nonasthmatic people.

PRECAUTIONSGeneral1.

During the administration of dobutamine, as with any adrenergic agent, ECG and blood pressure should be continuously monitored. In addition, pulmonary wedge pressure and cardiac output should be monitored whenever possible to aid in the safe and effective infusion of dobutamine.

2.

Hypovolemia should be corrected with suitable volume expanders before treatment with dobutamine is instituted.

3.

No improvement may be observed in the presence of marked mechanical obstruction, such as severe valvular aortic stenosis.

Usage Following Acute Myocardial Infarction

Clinical experience with dobutamine following myocardial infarction has been insufficient to establish the safety of the drug for this use. There is concern that any agent that increases contractile force and heart rate may increase the size of an infarction by intensifying ischemia, but it is not known whether dobutamine does so.

Laboratory Tests

Dobutamine, like other ß2-agonists, can produce a mild reduction in serum potassium concentration, rarely to hypokalemic levels. Accordingly, consideration should be given to monitoring serum potassium.

Drug Interactions

Animal studies indicate that dobutamine may be ineffective if the patient has recently received a ß-blocking drug. In such a case, the peripheral vascular resistance may increase.

Preliminary studies indicate that the concomitant use of dobutamine and nitroprusside results in a higher cardiac output and, usually, a lower pulmonary wedge pressure than when either drug is used alone.

There was no evidence of drug interactions in clinical studies in which dobutamine was administered concurrently with other drugs, including digitalis preparations, furosemide, spironolactone, lidocaine, glyceryl trinitrate, isosorbide dinitrate, morphine, atropine, heparin, protamine, potassium chloride, folic acid, and acetaminophen.

Carcinogenesis, Mutagenesis, Impairment of Fertility

Studies to evaluate the carcinogenic or mutagenic potential of dobutamine, or its potential to affect fertility, have not been conducted.

Pregnancy

Teratogenic Effects–Pregnancy Category B

Reproduction studies performed in rats at doses up to the normal human dose (10 mcg/kg/min for 24 h, total daily dose of 14.4 mg/kg), and in rabbits at doses up to twice the normal human dose, have revealed no evidence of harm to the fetus due to dobutamine. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

Labor and Delivery

The effect of dobutamine on labor and delivery is unknown.

Nursing Mothers

It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when dobutamine is administered to a nursing woman. If a mother requires dobutamine treatment, breastfeeding should be discontinued for the duration of the treatment.

Pediatric Use

Dobutamine has been shown to increase cardiac output and systemic pressure in pediatric patients of every age group. In premature neonates, however, dobutamine is less effective than dopamine in raising systemic blood pressure without causing undue tachycardia, and dobutamine has not been shown to provide any added benefit when given to such infants already receiving optimal infusions of dopamine.

Geriatric Use

Of the 1893 patients in clinical studies who were treated with dobutamine, 930 (49.1%) were 65 and older. No overall differences in safety or effectiveness were observed between these and younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or drug therapy.

ADVERSE REACTIONS

Increased Heart Rate, Blood Pressure, and Ventricular Ectopic Activity

A 10- to 20-mm increase in systolic blood pressure and an increase in heart rate of 5 to 15 beats/minute have been noted in most patients (see WARNINGS regarding exaggerated chronotropic and pressor effects). Approximately 5% of patients have had increased premature ventricular beats during infusions. These effects are dose related.

Hypotension

Precipitous decreases in blood pressure have occasionally been described in association with dobutamine therapy. Decreasing the dose or discontinuing the infusion typically results in rapid return of blood pressure to baseline values. In rare cases, however, intervention may be required and reversibility may not be immediate.

Reactions at Sites of Intravenous Infusion

Phlebitis has occasionally been reported. Local inflammatory changes have been described following inadvertent infiltration. Isolated cases of cutaneous necrosis (destruction of skin tissue) have been reported.

Miscellaneous Uncommon Effects

The following adverse effects have been reported in 1% to 3% of patients: nausea, headache, anginal pain, nonspecific chest pain, palpitations, and shortness of breath.

Isolated cases of thrombocytopenia have been reported.

Administration of dobutamine, like other catecholamines, can produce a mild reduction in serum potassium concentration, rarely to hypokalemic levels (see PRECAUTIONS).

OVERDOSAGEOverdoses of dobutamine have been reported rarely. The following is provided to serve as a guide if such an overdose is encountered.

Signs and Symptoms

Toxicity from dobutamine is usually due to excessive cardiac ß-receptor stimulation. The duration of action of dobutamine is generally short (T1/2= 2 minutes) because it is rapidly metabolized by catechol-0-methyltranferase. The symptoms of toxicity may include anorexia, nausea, vomiting, tremor, anxiety, palpitations, headache, shortness of breath, and anginal and nonspecific chest pain. The positive inotropic and chronotropic effects of dobutamine on the myocardium may cause hypertension, tachyarrhythmias, myocardial ischemia, and ventricular fibrillation. Hypotension may result from vasodilation.

Treatment

To obtain up-to-date information about the treatment of overdose, a good resource is your certified Regional Poison Control Center. Telephone numbers of certified poison control centers are listed in the Physicians’ Desk Reference (PDR). In managing overdosage, consider the possibility of multiple drug overdoses, interaction among drugs, and unusual drug kinetics in your patient.

The initial actions to be taken in a dobutamine overdose are discontinuing administration, establishing an airway, and ensuring oxygenation and ventilation. Resuscitative measures should be initiated promptly. Severe ventricular tachyarrhythmias may be successfully treated with propranolol or lidocaine. Hypertension usually responds to a reduction in dose or discontinuation of therapy.

Protect the patient’s airway and support ventilation and perfusion. If needed, meticulously monitor and maintain, within acceptable limits, the patient’s vital signs, blood gases, serum electrolytes, etc.

If the product is ingested, unpredictable absorption may occur from the mouth and the gastrointestinal tract. Absorption of drugs from the gastrointestinal tract may be decreased by giving activated charcoal, which, in many cases, is more effective than emesis or lavage; consider charcoal instead of or in addition to gastric emptying. Repeated doses of charcoal over time may hasten elimination of some drugs that have been absorbed. Safeguard the patient’s airway when employing gastric emptying or charcoal.

Forced diuresis, peritoneal dialysis, hemodialysis, or charcoal hemoperfusion have not been established as beneficial for an overdose of dobutamine.

DOSAGE AND ADMINISTRATIONNote

Do not add dobutamine to 5% Sodium Bicarbonate Injection or to any other strongly alkaline solution. Because of potential physical incompatibilities, it is recommended that dobutamine not be mixed with other drugs in the same solution. Dobutamine should not be used in conjunction with other agents or diluents containing both sodium bisulfite and ethanol.

Preparation and Stability

At the time of administration, dobutamine must be further diluted in an IV container to at least a 50 mL solution using one of the following intravenous solutions as a diluent: 5% Dextrose Injection, 5% Dextrose and 0.45% Sodium Chloride Injection, 5% Dextrose and 0.9% Sodium Chloride Injection, 10% Dextrose Injection, Isolyte® M with 5% Dextrose Injection, Lactated Ringer’s Injection, 5% Dextrose in Lactated Ringer’s Injection, Normosol®-M in D5-W, 20% Osmitrol® in Water for Injection, 0.9% Sodium Chloride Injection, or Sodium Lactate Injection. Intravenous solutions should be used within 24 hours.

Recommended Dosage

Infusion of dobutamine should be started at a low rate (0.5 to 1 mcg/kg/min) and titrated at intervals of a few minutes, guided by the patient’s response, including systemic blood pressure, urine flow, frequency of ectopic activity, heart rate and (whenever possible) measurements of cardiac output, central venous pressure, and/or pulmonary capillary wedge pressure. In reported trials, the optimal infusion rates have varied from patient to patient, usually 2 to 20 mcg/kg/min but sometimes slightly outside of this range. On rare occasions, infusion rates up to 40 mcg/kg/min have been required to obtain the desired effect. Rates of infusion (mL/h) for dobutamine concentrations of 500 mcg/mL, 1000 mcg/mL, and 2000 mcg/mL necessary to attain various delivery rates of dobutamine (mcg/kg/min) for patients of different weights are given in Table 1.

Table 1 Dobutamine Injection USP Infusion Rate (mL/h) for 500 mcg/mL concentration

Drug Delivery Rate Patient Body Weight (kg)

(mcg/kg/min) 5 10 20 30 40 50 60 70 80 90 100 1100.5 0.3 0.6 1.2 1.8 2.4 3 3.6 4.2 4.8 5.4 6 6.61 0.6 1.2 2.4 3.6 4.8 6 7.2 8.4 9.6 10.8 12 13.2

2.5 1.5 3 6 9 12 15 18 21 24 27 30 335 3 6 12 18 24 30 36 42 48 54 60 66

7.5 4.5 9 18 27 36 45 54 63 72 81 90 9910 6 12 24 36 48 60 72 84 96 108 120 132

12.5 7.5 15 30 45 60 75 90 105 120 135 150 16515 9 18 36 54 72 90 108 126 144 162 180 198

17.5 10.5 21 42 63 84 105 126 147 168 189 210 23120 12 24 48 72 96 120 144 168 192 216 240 264

Dobutamine Injection USP Infusion Rate (mL/h) for 1000 mcg/mL concentration

Drug Delivery Rate Patient Body Weight (kg)(mcg/kg/min) 5 10 20 30 40 50 60 70 80 90 100 110

0.5 0.1 0.3 0.6 0.9 1.2 1.5 1.8 2.1 2.4 2.7 3 3.31 0.3 0.6 1.2 1.8 2.4 3 3.6 4.2 4.8 5.4 6 6.6

2.5 0.7 1.5 3 4.5 6 7.5 9 10.5 12 13.5 15 16.55 1.5 3 6 9 12 15 18 21 24 27 30 33

7.5 2.2 4.5 9 13.5 18 22.5 27 31.5 36 40.5 45 49.510 3 6 12 18 24 30 36 42 48 54 60 66

12.5 3.7 7.5 15 22.5 30 37.5 45 52.5 60 67.5 75 82.515 4.5 9 18 27 36 45 54 63 72 81 90 99

17.5 5.2 10.5 21 31.5 42 52.5 63 73.5 84 94.5 105 115.520 6 12 24 36 48 60 72 84 96 108 120 132

 

Dobutamine Injection USP Infusion Rate (mL/h) for 2000 mcg/mL concentration

Drug Delivery Rate Patient Body Weight (kg)(mcg/kg/min) 5 10 20 30 40 50 60 70 80 90 100 110

0.5 0.07 0.1 0.3 0.4 0.6 0.7 0.9 1 1.2 1.3 1.5 1.61 0.1 0.3 0.6 0.9 1.2 1.5 1.8 2.1 2.4 2.7 3 3.3

2.5 0.4 0.7 1.5 2 3 4 4.5 5 6 7 7.5 85 0.7 1.5 3 4.5 6 7.5 9 10.5 12 13.5 15 16.5

7.5 1.1 2.2 4.5 7 9 11 13.5 16 18 20 22.5 2510 1.5 3 6 9 12 15 18 21 24 27 30 33

12.5 1.9 3.7 7 11 15 19 22.5 26 30 34 37.5 4115 2.2 4.5 9 13.5 18 22.5 27 31.5 36 40.5 45 49.5

17.5 2.6 5.2 10.5 15.7 21 26.2 31.5 36.7 42 47.2 52.5 57.720 3 6 12 18 24 30 36 42 48 54 60 66

 

Concentrations of up to 5,000 mcg/mL have been administered to humans (250 mg/50 mL). The final volume administered should be determined by the fluid requirements of the patient.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

HOW SUPPLIEDDobutamine Injection USP, 20 mL single dose vial contains dobutamine hydrochloride, equivalent to 250 mg dobutamine per 20 mL; ten vials per carton. NDC 55390-560-90.

Store at controlled room temperature, 15° to 30°C (59° to 86°F) [see USP].

Manufactured by: Ben Venue Laboratories, Inc., Bedford, Ohio 44146

Manufactured for: Bedford Laboratories™,Bedford, OH 44146

June 2007                                                                                                                   DBP05

VIAL LABEL

Vial Label

Diambil dari: publichealthnote.blogspot.com/2012/02/dopamin.html

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Saturday, February 25, 2012

Dopamin

Sediaan:

Injeksi (Ampul) 10 mg/ml, 20 mg/ml, 40 mg/ml

Cara Kerja Obat:

Dopamine adalah agen vasopressor dan inotropic. Dopamine bekerja dengan cara meningkatkan kekuatan memompa pada jantung dan suplai darah ke ginjal dan digunakan untuk meningkatkan fungsi jantung ketika jantung tak mampu memompa cukup darah.

Indikasi:

Memperbaiki keseimbangan hemodinamik pada kondisi sindroma syok terhadap infark miokardial, trauma, syok sepsis, operasi terbuka gagal jantung, gagal ginjal dan serangan jantung kronis.

Kontraindikasi:

Hipersensitif terhadap sulfit (sediaan yang mengandung natrium bisulfit), takiaritmia, phaeochromocytoma, fibrilasi ventrikular.

Dosis:

Infus I.V (pemberiannya memerlukan pompa infus) :

- Bayi : 1-20 mcg/kg/menit, infus kontinyu , titrasi sampai respon yang diharapkan

- Anak-anak : 1-20 mcg/kg/menit, maksimum 50 mcg/kg/menit, titrasi sampai respon yang diharapkan.

- Dewasa : 1-5 mcg/kg/menit sampai 20 mcg/kg/menit, titrasi sampai respon yang diharapkan. Infus boleh ditingkatkan 4 mcg/kg/menit pada interval 10-30 menit sampai respon optimal tercapai.

- Jika dosis > 20-30 mcg/kg/menit diperlukan, dapat menggunakan presor kerja langsung (seperti epinefrin dan norepinefrin).

Peringatan dan Perhatian:

- Hipovolemia harus diperbaiki sebelum pengobatan dilakukan.

- Hindari pada pasien dengan pheochromocytoma atau hipertiroidisme dan kemunculan tachyarrhythmias atau fibrilasi ventrikular.

- Gunakan dengan hati-hati dan dalam dosis rendah pada pasien dengan syok secondary terhadap MI, pasien dengan riwayat peripheral vascular disease (PVD) berisiko meningkatkan kemungkinan terkena ischemia akut.

Efek Samping:

- Sering : denyut ektopik, takikardia, sakit karena angina, palpitasi, hipotensi, vasokonstriksi, sakit kepala, mual, muntah, dispnea.

- Jarang : bradikardia, aritmia ventrikular (dosis tinggi), gangrene, hipertensi, ansietas, piloereksi, peningkatan serum glukosa, nekrosis jaringan (karena ekstravasasi dopamin), peningkatan tekanan intraokular, dilatasi pupil, azotemia, polyuria.

Tifoid inet

Diambil dari : http://www.abclab.co.id/?p=345

Step ladder who pain: http://www.who.int/cancer/palliative/painladder/en/

WHO's cancer pain ladder for adults

WHO has developed a three-step "ladder" for cancer pain relief in adults.

If pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. To calm fears and anxiety, additional drugs – “adjuvants” – should be used. 

To maintain freedom from pain, drugs should be given “by the clock”, that is every 3-6 hours, rather than “on demand” This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80-90% effective. Surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective. In the case of cancer pain in children, WHO recommends a two step ladder.

For further information see WHO Guidelines on the pharmacological treatment of persisting pain in children with medical illnesses at:

WHO Analgesic LadderDiambil dari: http://www.paincommunitycentre.org/article/who-analgesic-ladder-0

This article discusses the WHO analgesic ladder for those who are unfamiliar with it and its use in practice.

Learning outcomes:

to understand the basis of the WHO analgesic ladder to understand the concept of multimodal analgesia

WHO Analgesic Ladder

An analgesic  is a member of the group of drugs which are used to relieve pain, also known as “painkillers”. The word analgesic derives from Greek an ("without") and algos ("pain").

The analgesic ladder was designed by the World Health Organisation (WHO) [1] to assist the healthcare prescriber in the prescription of analgesic drugs by suggesting a logical strategy for managing pain in a multitude of pain situations.

The ladder advocates a stepped approach to the use of painkillers from these analgesic groups:

Simple analgesics i.e. paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) Weak opioids i.e. tramadol, codeine Strong opioids i.e. morphine, fentanyl, oxycodone, pethidine Adjuvants - adjuvant analgesics are drugs which were not originally for pain but rather for

other conditions but have been found to be effective in difficult to manage pain, particularly neuropathic pain. They are a diverse group of drugs that includes antidepressants, anticonvulsants (antiseizure drugs), and others.

At every step of the analgesic ladder non-opioid analgesics form the basis of the pain management. Paracetamol and NSAID (if not contraindicated) should always therefore be prescribed with opioid analgesia (weak or strong). This is known as multi-modal analgesia and is the concept that pain is best managed, not by a single drug or therapy, but by combinations, which maximise efficacy whilst keeping side-effects low. Evidence has demonstrated that when this happens pain relief is better, smaller amounts of pain killers are needed and less side effects occur.

Figure 1: WHO Analgesic Ladder

The WHO advocates that these analgesics should be given “by the clock”, that is every 3-6 hours, rather than “on demand.” This stepped approach of administering the right drug in the right dose at the right time is inexpensive and generally effective in managing acute pain.

The advantages of the analgesic ladder include:

Simplicity, as only a few analgesic groups are used Flexibility to a large variety of pain situations and also to prescribers globally. By referring to

drug classes, rather than specific drugs, the ladder maintains a level of flexibility that allows clinicians to work within their set regulations and limitations.

Safety, in that safest drugs are used first in their lowest effective dose Emphasis on multimodal analgesia.

Its disadvantages include:

It may be too simplistic for management of certain types of pain, especially neuropathic pain or for those who are opioid dependant.

It suggests that analgesics should be administrated orally, which may occasionally not be appropriate, for example, when patients are 'nil by mouth'.

References

1. Organisation W . Analgesic Ladder. World Health Organization; 1986.

World Health Organization Ladder

Diambil dari: http://www.va.gov/PAINMANAGEMENT/World_Health_Organization_Ladder.asp

The WHO ladder portrays a progression in the doses and types of analgesic drugs for effective pain management. The best choice of modality often changes as the patient’s condition and the characteristics of the pain change.The first step in this approach is the use of acetaminophen, aspirin, or another Non-steroidal Anti-inflammatory Drug (NSAID) for mild to moderate pain. Adjuvant drugs to enhance analgesic efficacy, treat concurrent symptoms that exacerbate pain, and provide independent analgesic activity for specific types of pain may be used at any step.

When pain persists or increases, an opioid such as codeine or hydrocodone should be added (not substituted) to the NSAID. Opioids at this step are often administered in fixed dose combinations with acetaminophen or aspirin because this combination provides additive analgesia. Fixed combination products may be limited by the content of acetaminophen or NSAID, which may produce dose-related toxicity. When higher doses of opioid are necessary, the third step is used. At this step separate dosage forms of the opioid and non-opioid analgesic should be used to avoid exceeding maximally recommended doses of acetaminophen or NSAID.

Pain that is persistent or is of moderate to severe intensity from the outset should be treated by increasing the dosage or with more potent opioids. Drugs such as codeine or hydrocodone are replaced with more potent opioids (usually morphine, hydromorphone, methadone, fentanyl, or levarphanol). 

Medications for persistent cancer-related pain should be administered on an around-the-clock schedule, with additional "as needed" doses, because regularly scheduled dosing maintains a constant level of drug in the body and helps to prevent a recurrence of pain. Patients who have moderate to severe pain when first seen by the clinician should be started at the second or third step of the ladder.

Reference: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research Clinical Practice Guidelines, Number 9, March 1994.

Syringe pump

http://materi-sehat.blogspot.com/2011/03/rumus-perhitungan-cairan-dengan-syring.html