What is the recommended order of inotropes (inotropic agents) to be started?

From the Guidelines

The recommended order of inotropes typically begins with dobutamine as first-line therapy at 2.5-20 mcg/kg/min for patients with cardiogenic shock or acute decompensated heart failure, as suggested by the most recent guidelines 1.

Inotrope Selection

The choice of inotrope is guided by the patient's hemodynamic profile and underlying pathophysiology.

• Dobutamine is preferred as the initial agent due to its ability to increase contractility without significant effects on heart rate or blood pressure 1.
• If inadequate response occurs, milrinone (0.375-0.75 mcg/kg/min, with optional 25-75 mcg/kg loading dose) is often added or substituted, especially in patients with pulmonary hypertension or those on beta-blockers 1.
• For refractory cases, epinephrine (0.01-0.5 mcg/kg/min) or norepinephrine (0.01-3 mcg/kg/min) may be introduced, with norepinephrine preferred when hypotension is prominent 1.

Dosing and Monitoring

Dose adjustments should be made gradually (every 5-15 minutes) based on patient response, with careful attention to blood pressure, heart rate, cardiac output, and end-organ perfusion.

• The development of tachyphylaxis should be acknowledged, and the choice of agent may need to be changed during longer periods of support 1.
• Lower doses of parenteral inotropic drugs are preferred to minimize adverse effects 1.

Special Considerations

The underlying pathophysiology influences selection—beta-agonists like dobutamine increase contractility but may worsen tachyarrhythmias, while phosphodiesterase inhibitors like milrinone provide inotropic support with vasodilation but require dose adjustment in renal dysfunction 1.

From the Research

Order of Inotropes

The order of inotropes to be started is not strictly defined, but the choice of inotrope depends on the patient's condition and the desired effect.

• Norepinephrine (NE) is often used as a first-line vasopressor to achieve adequate arterial pressure 2.
• If tissue and organ perfusion remain inadequate, an inotrope such as dobutamine may be added to increase cardiac output 2.
• Low doses of epinephrine or dopamine may be used for inotropic support, but high doses of these drugs carry an excessive risk of adverse events 2.
• Milrinone and dobutamine have similar effectiveness and safety profiles, but with differences in adverse events, and the choice between them may depend on tolerability of adverse events 3.

Considerations for Inotrope Therapy

When selecting an inotrope, several factors should be considered, including:

• The patient's hemodynamic status and the need for increased cardiac output or blood pressure
• The potential risks and benefits of each inotrope, including the risk of adverse events such as arrhythmias or hypotension
• The patient's underlying medical conditions and comorbidities
• The results of studies comparing the effectiveness and safety of different inotropes, such as dobutamine and milrinone 3.

Patient-Tailored Approach

A patient-tailored approach to inotrope therapy is recommended, with the use of inotropes guided by hemodynamic evidence of low cardiac output associated with signs of inadequate tissue perfusion 4.

• This approach may involve the use of dobutamine or other inotropes, but only when necessary and at the lowest effective dose.
• The goal of inotrope therapy is to restore adequate tissue perfusion and improve patient outcomes, while minimizing the risk of adverse events.