VASOPRESSORS DEMYSTIFIED by Nick Mark MD ONE onepagericu.

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Does this person need vasopressors? EPINEPHRINE
• Consider all etiologies of shock (cardiogenic, obstructive, α > β1 = β2
hypovolemic, and distributive); are other treatments (fluids, NOREPINEPHRINE 0.5 – 30 mcg/min
blood transfusions, inotropes, etc.) indicated? NOREPINEPHRINE (a.k.a. Levophed, ‘levo’, noradrenaline)
• Is there evidence of hypoperfusion? Is BP accurate?
DOPAMINE MIXED α/β α > β1 Good general purpose pressor with
α > β1 combined vasoconstriction and inotropy
Often used first line for septic shock.
What is my blood pressure goal?
Use mean arterial pressure (MAP) as your goal; target MAP >65
DOBUTAMINE EPINEPHRINE 1 – 10 mcg/min
MAP > 60 mmHg may be equivalent to MAP > 65 mmHg in (a.k.a. adrenaline)
patients over 65 years old β1 > > α Ideal for anaphylactic shock (also
Although higher MAP goals are generally not beneficial, some
patients (neurological issues, stenosed coronaries, etc) may
(inotropes not
vasopressors)
PURE β PURE α has bronchodilator activity)
Increases lactic acid production
benefit from higher individualized MAP goals
ISOPROTERENOL PHENYLEPHRINE
Β1/ Β2 only
VASOPRESSIN 0.01 – 0.06 units/min
α only Long half-life; hard to titrate, often used at
Which vasopressor to start?
Treat the underlying physiology (is a mixed vasoconstriction and a fixed dose. Non-catecholamine pressor;
Good adjunct for septic shock
inotropy desirable?, High PA pressures ! VASO, Anaphylaxis ! EPI (+) Inotropy Vasoconstriction Unlike other pressors it does not ↑ PA
Vasodilation pressures but higher risk for gut ischemia

Push-dose versus continuous infusion Central versus peripheral administration?

Push-dose good for transient hypotension (e.g. post intubation) or PHENYLEPHRINE 50 – 360 mcg/min
Do not wait for central access to begin pressors if needed! (a.k.a. Neosynephrine ‘neo’)
when pressor infusion is not immediately available. Two options:
It is safe and effective to give vasopressors peripherally if: Pure α effects; good for pure
• PHENYLEPHRINE syringe (pre-mixed); administer 50-100 mcg
• The IV is newly placed, in a larger vein (4mm or larger) and vasodilatory states or in patients who
EPINEPHRINE: combine 1 cc of a 10 cc Epi syringe (1:10,000
not in the hand, wrist, or antecubital fossa cannot tolerate inotropy (tachycardia or
ACLS dose) with 9 cc of saline (makes 100 mcg epi in 10 cc);
• You have a protocol to monitor for extravasation Afib w/ RVR)
administer 10-20 mcg at a time (repeat q1 minute)
• You know what to do if there is extravasation (protocol)
If a patient requires push dose, expect a need for an ongoing
PHENYLEPHRINE, NOREPINEPHRINE, EPINEPHRINE can be
infusion.
given peripherally. (Avoid VASOSPRESSIN peripherally) In the
DOPAMINE 1 – 20 mcg/kg/min
Mixed effects; May be vasodilatory
case of high dose pressors, multiple pressors, or prolonged
at low doses (hard to ‘wean’ off)
infusion central venous access is recommended.
Add additional pressors if needed In patients with cardiogenic shock,
Again consider the physiology. Does this person need inotropy? DA is more arrythmogenic than NE.
Do they need blood products/fluid? Steroids? Are they acidemic? (requiring > 2 pressors)
For sepsis, no benefit to starting in a particular sequence, though
NE ! VASO ! EPI ! PHENYL ! DA is common. METHYLENE BLUE
Vasopressor refractory shock STEROIDS

CC BY-SA 3.0 v1.2 (2021-02-23)

Am I treating the cause of shock? Stress Dose Steroids Nitric oxide scavenger that can
• Consider differential d/dx of shock (e.g. • Hydrocortisone 50 mg q6 hrs IV be used if pressor refractory
Weaning vasopressors don’t treat blood loss w/ pressors!) • Wean over days as pressor • 1 – 2 mg/kg SLOW IV push
• Acidosis decreases efficacy of pressors! requirement decreases • Good for refractory
Wean one pressor at a time; may be advantage to weaning VASO
Increase dose of pressors: EPI, NE, DA, • Reduces pressor hypotension or hypotension
before NE. Some patients may benefit from adding MIDODRINE
PHENYL do not have a true max dose. requirement/duration due to vasoplegia (e.g. after
10 mg 8 hr PO to facilitate weaning from pressors/liberating from
Consider stress dose steroids and alternative agents (such as cardiopulmonary bypass)
ICU. Consider contraindications and renal dosing.
methylene blue, angiotensin II) or interventions (VA ECMO)