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  • Title: Sympathomimetic agents in the treatment of shock.
    Author: Tarazi RC.
    Journal: Ann Intern Med; 1974 Sep; 81(3):364-71. PubMed ID: 4605195.
    Abstract:
    Sympathominetic drugs, and their uses in variously induced shock conditions, are the focus of this review. Sympathomimetic drugs can be classified according to: 1) the target organ, i.e., whether the heart or the peripheral vascular tree; 2) the type of action on the receptor site, i.e., direct or indirect; and 3) the type of adrenergic receptor stimulated (alpha or beta). Most sympathomimetic drugs are vasoconstrictors because of direct or indirect alpha-adrenergic receptor stimulation. Activation of beta-adrenergic receptors produces vasodilation, most evidently with isoproterenol. With few exceptions, vasoconstricting drugs are not selective in terms of vessels; infusion of norepinephrine decreases blood flow to skeletal muscle and it decreases renal, splanchnic, and cerebral blood flow. On the contrary, coronary flow increases because of the increased cardiac work and increase in arterial pressure. These pressor amines, therefore, are not innocuous drugs, and their administration should be very carefully monitored and the dose titrated to overloading the heart or inducing ventricular irritability. Either norepinephrine or metaraminil are the drugs preferred; they are given in amounts just sufficient to increase the intraarterial pressure to a mean of 80 mm of Hg, for higher levels may lead to reduction in cardiac index. A possible contraindication to drugs that markedly elevate peripheral resistance in myocardial infarction is associated mitral insufficiency. In noncoronary shocks, isoproterenol may be the drug of choice, unless arterial pressure is extremely low. Besides these general hemodynamic factors, other considerations to be weighed in the choice of a sympathominetic drug include rapidity of action, need for constant monitoring, and amount of intravenous fluid tolerated by the patients. Many factors may interfere with the response to these agents, most prominent among these are disturbances in acid-base balance. Previous use of catecholamine-depleting agents can markedly reduce the response to indirectly acting sympathomimetic agents.
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