> IV INF 2.5-15 mcg/kg/min

> Maximum dose: 40 mcg/kg/min

§  Adjunctive therapy in cardiac surgery

§  Dobutamine is indicated for patients who require positive inotropic support in the treatment of cardiac decompensation due to depressed contractility resulting either from organic heart disease or from cardiac surgical procedures.

§  Dobutamine increases cardiac output after acute myocardia   infarction without exacerbating myocardia  infarction or ventricular dysrhythmias.

§  Ventricular tachycardia

§  Idiopathic hypertrophic subaortic stenosis

§  Safe use during pregnancy (category C), lactation, for children, and anginal MI is not established.

§  CNS: Headache, tremors, paresthesias, mild leg cramps, nervousness, fatigue (with overdosage)

§  CV: Increased heart rate and BP, premature ventricular beats, palpitation, anginal pain

§  GI: Nausea, vomiting

§  Other: Nonspecific chest pain, shortness of breath.

§  Correct hypovolemia by administration of appropriate volume expanders prior to initiation of therapy.

§  Monitor therapeutic effectiveness. At any given dosage level, drug takes 10–20 min to produce peak effects.

§  Monitor ECG and BP continuously during administration.

§  Note: Marked increases in blood pressure (systolic pressure is the most likely to be affected) and heart rate, or the appearance of arrhythmias or other adverse cardiac effects are usually reversed promptly by reduction in dosage.

§  Observe patients with preexisting hypertension closely for exaggerated pressor response.

§  Note: Tolerance has been observed with continuous or prolonged infusions; adverse reactions are no different than those seen with shorter infusions.

§  Monitor I&O ratio and pattern. Urine output and sodium excretion generally increase because of improved cardiac output and renal perfusion.

§  Report anginal pain to physician promptly.

§  Do not breast feed while taking this drug without consulting physician.

    > Adult: SC 5000 U q8–12h

§  Treatment of Thromboembolism 

     > Adult: IV 5000-U bolus dose, then 20,000–40,000 U infused over 24 h, dose adjusted to maintain desired APTT or 5000–10,000 U IV piggyback q4–6h SC 10,000–20,000 U followed by 8000–20,000 U q8–12h 

  > Child: IV 50 U/kg bolus, then 20,000 U/m2/24 h or 50–100 U/kg q4h or 15–25 U/kg/h

§  The rationale for the use of heparin therapy as an adjunct to thrombolytic treatment of acute myocardial infarction, or even in patients who spontaneously lyse a clot, is to prevent thrombosis of the coronary artery during the recovery period.

§  Active bleeding, bleeding tendencies (hemophilia, purpura, thrombocytopenia)

§  Jaundice

§  Ascorbic acid deficiency

§  Inaccessible ulcerative lesions

§  Visceral carcinoma 

§  Open wounds

§  Extensive denudation of skin

§  Suppurative thrombophlebitis

§  Advanced kidney, liver, or biliary disease

§  Active tuberculosis

§  Bacterial endocarditis

§  Continuous tube drainage of stomach or small intestines

§  Threatened abortion

§  Suspected intracranial hemorrhage

§  Severe hypertension

§  Recent surgery of eye, brain, or spinal cord

§  Spinal tap

§  Shock.

§  Body as a Whole: Fever, chills, urticaria, pruritus, skin rashes, itching and burning sensations of feet, numbness and tingling of hands and feet, elevated BP, headache, nasal congestion, lacrimation, conjunctivitis, chest pains, arthralgia, bronchospasm, anaphylactoid reactions. 

§  Endocrine: Osteoporosis, hypoaldosteronism, suppressed renal function, hyperkalemia; rebound hyperlipidemia (following termination of heparin therapy). 

§  GI: increased AST, ALT. 

§  Urogenital: Priapism (rare). 

§  Skin: Injection site reactions: pain, itching, ecchymoses, tissue irritation and sloughing; cyanosis and pains in arms or legs (vasospasm), reversible transient alopecia (usually around temporal area).

§  Lab tests: Baseline blood coagulation tests, Hct, Hgb, RBC, and platelet counts prior to initiation of therapy and at regular intervals throughout therapy.

§  Monitor APTT levels closely.

§  Note: In general, dosage is adjusted to keep APTT between 1.5–2.5 times normal control level.

§  Draw blood for coagulation test 30 min before each scheduled SC or intermittent IV dose and approximately q4h for patients receiving continuous IV heparin during dosage adjustment period. After dosage is established, tests may be done once daily.

§  Patients vary widely in their reaction to heparin; risk of hemorrhage appears greatest in women, all patients >60 y, and patients with liver disease or renal insufficiency.

§  Monitor vital signs. Report fever, drop in BP, rapid pulse, and other S&S of hemorrhage.

§  Observe all needle sites daily for hematoma and signs of inflammation (swelling, heat, redness, pain).

§  Antidote: Have on hand protamine sulfate (1% solution), specific heparin antagonist.

§  Protect from injury and notify physician of pink, red, dark brown, or cloudy urine; red or dark brown vomitus; red or black stools; bleeding gums or oral mucosa; ecchymoses, hematoma, epistaxis, bloody sputum; chest pain; abdominal or lumbar pain or swelling; unusual increase in menstrual flow; pelvic pain; severe or continuous headache, faintness, or dizziness.

§  Note: Menstruation may be somewhat increased and prolonged; usually, this is not a contraindication to continued therapy if bleeding is not excessive.

§  Learn correct technique for SC administration if discharged from hospital on heparin.

§  Engage in normal activities such as shaving with a safety razor in the absence of a low platelet (thrombocyte) count. Usually, heparin does not affect bleeding time.

§  Caution: Smoking and alcohol consumption may alter response to heparin and are not advised.

§  Do not take aspirin or any other OTC medication without physician's approval.