Received: 14 November 2020 Revised: 30 April 2021 Accepted: 20 June 2021

DOI: 10.1111/vec.13230

ORIGINAL STUDY

Use of vasopressors for treatment of vasodilatory hypotension

in dogs and cats by Diplomates of the American College of
Veterinary Emergency and Critical Care

Kellyann M. Murphy DVM1 Mark Rishniw BVsc, MS, PhD, DACVIM2

Deborah C. Silverstein DVM, DACVECC1

1
Department of Clinical Studies and Advanced
Medicine, University of Pennsylvania School of
Veterinary Medicine, Philadelphia,
Pennsylvania, USA
2
Veterinary Information Network, Davis,
California, USA
Correspondence
Kellyann Murphy, Ryan Veterinary Hospital,
University of Pennsylvania, 3900 Spruce
Street, Philadelphia, PA 19104, USA.
Email: kmurphy02@gmail.com
Abstract
Objective: To identify the most common practices of Diplomates of the American Col-
lege of Veterinary Emergency and Critical Care (DACVECCs) as they relate to the
recognition and treatment of hypotension in dogs and cats, particularly concerning the
use of vasopressors in vasodilatory shock states.
Design: A survey regarding vasopressor use was sent to all active DACVECCs using the
Veterinary Information Network. Questions focused on respondent characteristics,
method of recognition of hypotension, triggers for initiation of vasopressor therapy,
first- and second-line vasopressor choice, and methods of determining response to
therapy.
Subjects: A total of 734 DACVECCs were invited to participate, and 203 Diplomates
(27.7%) completed the survey.
Results: For both dogs and cats, the most common first-line vasopressor was nore-
pinephrine (87.9% in dogs and 83.1% in cats). The most common second-choice
vasopressor was vasopressin (44.2% in dogs and 39.0% in cats). Cutoff values for
initiating vasopressor therapy varied between species and modality used for blood
pressure measurement. In general, most DACVECCs chose to initiate vasopressor
therapy at a Doppler blood pressure <90 mm Hg or a mean arterial pressure of <60 or
<65 mm Hg when using oscillometric or direct arterial blood pressure measurements
in dogs and cats.
Conclusions: Most DACVECCs adhere to published human guidelines when choosing
a first-line vasopressor. However, there is significant variability in blood pressure mea-
surement technique, cutoffs for initiation of vasopressor use, and choice of second-line
vasopressors.

KEYWORDS
blood pressure, critical care, norepinephrine, perfusion, vasopressin

Abbreviations: DABP, direct arterial blood pressure; DACVECCs, Diplomates of the American College of Veterinary Emergency and Critical Care; DBP, Doppler blood pressure; ER, emergency
room; MAP, mean arterial pressure; SAP, systolic arterial pressure; SSC, Surviving Sepsis Campaign.

© Veterinary Emergency and Critical Care Society 2022.

714 wileyonlinelibrary.com/journal/vec J Vet Emerg Crit Care. 2022;32:714–722.


MURPHY ET AL .
1 INTRODUCTION
Hypotension is a common problem in critically ill small animal veteri-
nary patients and can lead to significant morbidity and mortality if
not promptly corrected. The mortality rate for hypotensive dogs that
present to the emergency room (ER) is higher if the hypotension does
not respond to fluid administration.1 While there is no widely accepted
definition of hypotension in veterinary medicine, other studies have
used a Doppler blood pressure (DBP) or systolic arterial pressure
(SAP) ≤90 mm Hg in dogs.1,2 Ruffato et al3 defined intraoperative
hypotension in dogs as SAP < 87 mm Hg or mean arterial pressure
(MAP) <62 mm Hg. Critically ill cats with a DBP ≤ 90 mm Hg are sig-
nificantly less likely to survive to discharge than normotensive cats.
Additionally, hypotensive cats that respond to treatment are 4 times
more likely to survive than nonresponders.4
Treatment of hypotension depends on the suspected underlying
cause. Hypotension due to vasodilation most commonly occurs in
sepsis, although prolonged and severe hypotension of any cause can
ultimately result in vasodilatory shock. Other disease states that
have been proposed to cause vasodilation include nitrogen intoxica-
tion, carbon monoxide intoxication, metformin intoxication, certain
mitochondrial diseases, cyanide poisoning, anaphylaxis, liver failure,
and glucocorticoid deficiency.5 For patients with vasodilatory shock,
vasoactive substances are commonly employed to correct decreased
arterial blood pressure. Currently, there are no published guidelines
for the treatment of hypotension in veterinary patients. In people
with hypotension, early goal-directed therapy in which central venous
pressure, MAP, and central venous oxygen saturation are used as end-
points to guide therapy has been proposed as a superior protocol to
treating severe sepsis and septic shock.6 There is conflicting evidence,
however, as to whether or not this algorithm provides a benefit over
conventional therapy.7–9 Due to the lack of clinical studies evaluating
treatment protocols for hypotension in dogs and cats, current thera-
pies are largely clinician dependent and based on extrapolations from
human literature as well as clinical experience.
The goal of this survey was to identify the most common practices
of Diplomates of the American College of Veterinary Emergency and
Critical Care (DACVECCs) as they relate to the diagnosis and treat-
ment of hypotension in dogs and cats, particularly concerning the use
of vasopressors in vasodilatory shock states.
2 METHODS
A survey was created using a web-based survey enginea and was
distributed to all DACVECCs via an email listserv. The survey was
open from July 1, 2019 to July 22, 2019. The questions were created
by one of the authors (D.C.S.) and tested internally prior to release
to the DACVECCs. Questions focused on respondent characteristics,
method of diagnosis of hypotension, triggers for initiation of vasopres-
sor therapy, first- and second-line vasopressor choice, and methods of
determining response to therapy (Supporting Information). The blood
pressure targets presented as possible answers in the survey were
14764431, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vec.13230 by David Alzate - Universidad Ces , Wiley Online Library on [09/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
715
conventionally established based on previous research in both human
and animal medicine that not only determined normal ranges but also
defined hypotension for prognosis or intervention.1–4,10–14
The data were analyzed using descriptive statistics; no inferential
statistical analyses of the data were performed. For questions that
were not answered by all respondents, percentages were calculated
out of the total number of actual responses received. For the ques-
tions regarding the specific blood pressure measurements at which
they would consider initiating vasopressor therapy, respondents were
offered choices of specific critical MAP or SAP values, an option of
“I use a combination of MAP and SAP,” or an option of “I use either
a critical MAP or SAP.” The option “I use a combination of MAP and
SAP” indicated they would require both of the measurements to have
reached a critical value, while “I use either a critical MAP or SAP” indi-
cated they would initiate vasopressor therapy when 1 or the other of
these values reached a critical value.
3 RESULTS
A total of 734 active Diplomates were invited to participate in the
survey. Of these, 219 DACVECCs responded to the survey. Six-
teen responses were excluded because they were incomplete, leaving
203 analyzable responses (27.7% of DACVECCs contacted). Eight
respondents (3.9%) reported working exclusively in an ER, 97 (47.8%)
reported working exclusively in an ICU, and 98 (48.3%) reported work-
ing in both. The majority of respondents (67.5%, n = 137) worked in
private specialty referral practices. The remainder worked in a univer-
sity teaching hospital (30.0%, n = 61), an ER-only practice (2.0%, n = 4),
or a general practice (0.5%, n = 1).
3.1 Dogs
All 203 respondents reported that they treat dogs with hypotension
in their practice; however, 3 respondents reported that they never
treated patients similar to the one in the survey question and thus
were not asked to respond to subsequent survey questions. The 200
remaining respondents were invited to continue with the survey. Five
respondents (2.5%) reported treating similar patients on a daily basis,
54 (27.0%) treat every week, 80 (40.0%) treat every month, 39 (19.5%)
treat every 1–3 months, and 22 (11.0%) treat similar patients less than
every 3 months.
A total of 198 responses were received regarding DBP monitor-
ing in dogs. Eighty-one (40.9%) respondents would consider using a
vasopressor when the measurement is <90 mm Hg. Fifty-nine (29.8%)
would treat when the measurement is <80 mm Hg, 28 (14.1%) when
the measurement is <70 mm Hg, 21 (10.6%) when the measurement
is <100 mm Hg, and 5 (2.5%) when the measurement is <60 mm Hg.
Four respondents (2.0%) stated that they would not use DBP measure-
ment in dogs (Figure 1).
A total of 199 responses were received regarding oscillometric
blood pressure monitoring in dogs. One hundred and nineteen (59.8%)

716
F I G U R E 1 Cutoff diastolic blood pressure value for initiating
vasopressor therapy in dogs among Diplomates of the American
College of Veterinary Emergency and Critical Care
F I G U R E 2 Cutoff oscillometric value for initiating vasopressor
therapy in dogs among Diplomates of the American College of
Veterinary Emergency and Critical Care. *Other includes respondents
who indicated that they would use either an SAP or MAP or a
combination of SAP and MAP. MAP, mean arterial pressure; SAP,
systolic arterial pressure
respondents reported using the MAP value as their treatment trigger
(MAP < 70 mm Hg, n = 20, 10.1%; MAP < 65 mm Hg, n = 49, 24.6%;
MAP < 60 mm Hg, n = 50, 25.1%). Only 18 (9.0%) respondents reported
using an SAP to determine treatment (SAP < 100 mm Hg, n = 4, 2.0%;
SAP < 90 mm Hg, n = 10, 5.0%; SAP < 80 mm Hg, n = 4, 2.0%). Twenty-
nine respondents (14.5%) stated they use a combination of MAP and
SAP when diagnosing hypotension, and 11 (5.5%) stated they use either
a critical MAP or SAP. Twenty-two respondents (11.1%) stated that
they would not use oscillometric blood pressure measurement in dogs
(Figure 2).
14764431, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vec.13230 by David Alzate - Universidad Ces , Wiley Online Library on [09/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MURPHY ET AL .
F I G U R E 3 Cutoff DABP value for initiating vasopressor therapy
in dogs among Diplomates of the American College of Veterinary
Emergency and Critical Care. *Other includes respondents who
indicated that they would use either an SAP or MAP or a combination
of SAP and MAP. DABP, direct arterial blood pressure; MAP, mean
arterial pressure; SAP, systolic arterial pressure
Of the 200 respondents, 21 (10.5%) stated they did not use
direct arterial blood pressure (DABP) measurement in dogs. Most
respondents (60.5%, n = 121) chose to treat based on a direct MAP
(MAP < 70 mm Hg, n = 20, 10.0%; MAP < 65 mm Hg, n = 60, 30.0%;
MAP < 60 mm Hg, n = 41, 20.5%). Only 29 (14.5%) chose to treat based
on SAP (SAP < 100 mm Hg, n = 4, 2.0%; SAP < 90 mm Hg, n = 18, 9.0%;
SAP < 80 mm Hg, n = 6, 3.0%; SAP < 70 mm Hg, n = 1, 0.5%). Twenty-
two respondents (11%) stated they use a combination of direct MAP
and SAP when diagnosing hypotension, and 7 respondents (3.5%) use
either a critical MAP or SAP (Figure 3).
Regardless of the monitoring method, 29 (14.5%) respondents
reported starting treatment based on 1 blood pressure measure-
ment, while 171 (85.5%) respondents reported requiring multiple
measurements before initiating treatment. For those who use multiple
measurements, 167 provided an answer regarding how many measure-
ments they use. Eighty-six (51.5%) respondents use 3 measurements,
74 (44.3%) use 2 measurements, 1 (0.6%) uses 4 measurements,
5 (3.0%) use 5 measurements, and 1 (0.6%) uses 6 measurements.
Of those who use multiple measurements, 170 provided an answer
regarding how long they wait between measurements. A plurality of
respondents (44.1%, n = 75) reported waiting 2–5 minutes between
readings. Thirty specialists (17.6%) wait 1 minute between readings, 34
(20.0%) wait 6–10 minutes, 20 (11.8%) wait 11–15 minutes, 6 (3.5%)
wait 16–20 minutes, and 5 (2.9%) wait 21–30 minutes.
All 200 respondents answered the question regarding their first-
choice vasopressor. The majority of respondents (87.5%, n = 175)
reported choosing norepinephrine as their first-choice vasopressor
for the dog described in the survey. The second most common first-
choice vasopressor was dopamine (11.0%, n = 22). Phenylephrine and
vasopressin were each chosen as first choice by 1 respondent (0.5%
each). One respondent (0.5%) chose “Other” and stated that they would
choose either dopamine or norepinephrine depending on the case
(Figure 4).

MURPHY ET AL .
F I G U R E 4 First-choice vasopressor for vasodilatory shock in dogs
among Diplomates of the American College of Veterinary Emergency
and Critical Care
In determining response to treatment, 126 respondents (63.0%)
consider an increase in SAP > 10 mm Hg as a positive response, 102
(51.0%) consider an increase in MAP > 10 mm Hg a positive response,
63 (31.5%) consider normalization of SAP a positive response, and 51
(25.5%) consider normalization of MAP a positive response. Twenty-
three respondents (11.5%) stated that they use “Other” parameters to
determine a positive response (either in addition to or in place of one of
the previously mentioned options).
Approximately one-third (31.5%, n = 63) of respondents wait 6–
10 minutes before deeming the response inadequate, 30.0% (n = 60)
wait 11–15 minutes, 15.5% (n = 31) wait 1–5 minutes, 13.0% (n = 26)
wait 16–20 minutes, 9.5% (n = 19) wait 21–30 minutes, and 1
respondent (0.5%) waits more than 30 minutes.
If the initial response is deemed inadequate, most respondents
(n = 169, 84.5%) reported that they would titrate up the first-choice
vasopressor to a maximal dose before adding in a second vasopres-
sor. For these respondents, if they reach the maximum dose of the
first vasopressor and there is still an inadequate response, the majority
(91.7%, n = 155) would add in a second vasopressor, while the remain-
der (8.3%, n = 14) would switch to another vasopressor. Thirty (15.0%)
respondents would add in a second vasopressor before reaching the
maximum dose of the first vasopressor, and 1 respondent (0.5%) would
switch to a second vasopressor rather than increasing to a maximum
dose of the first vasopressor.
Of the 185 respondents who chose to add a second vasopres-
sor (regardless of whether or not the first drug was titrated to a
maximal dose), 184 responded to the question regarding their second-
choice vasopressor. Approximately half (45.6%, n = 84) of respondents
would use vasopressin as their second-choice vasopressor, followed
by dopamine (30.4%, n = 56), norepinephrine (10.9%, n = 20), and
phenylephrine (2.2%, n = 4). Twenty respondents (10.9%) indicated
that they would choose another vasopressor not listed, most com-
14764431, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vec.13230 by David Alzate - Universidad Ces , Wiley Online Library on [09/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
717
F I G U R E 5 Second-choice vasopressor for vasodilatory shock in
dogs among Diplomates of the American College of Veterinary
Emergency and Critical Care
monly dobutamine (6.0%, n = 11) or epinephrine (4.9%, n = 9). The 15
respondents who reported switching to a different vasopressor most
commonly chose dopamine (40.0%, n = 6), followed by vasopressin
(26.7%, n = 4), norepinephrine (26.7%, n = 4), and phenylephrine (6.7%,
n = 1).
A total of 199 respondents provided an answer to the question
regarding their second-choice vasopressor in dogs. Overall, regard-
less of whether or not the respondent chose to add in or switch to a
second drug, the most common second-choice drug was vasopressin
(44.2%, n = 88), followed by dopamine (30.7%, n = 61), norepinephrine
(12.1%, n = 24), dobutamine (5.5%, n = 11), epinephrine (4.5%, n = 9),
and phenylephrine (2.5%, n = 5). One respondent (0.5%) chose “Other”
and indicated their choice would depend on various other factors
(Figure 5).
3.2 Cats
Of the 203 total included survey responses, most respondents (72.4%,
n = 147) stated that they would treat a cat with a similar clinical
scenario the same way as they would a dog; 1 of these respondents
reported that they did not treat patients similar to the one in the sur-
vey and was not invited to answer the subsequent survey questions.
Only 56 respondents (27.6%) stated they would use different proto-
cols for a cat. In order to assess the most common practices used
to treat hypotensive cats, the 56 responses describing feline-specific
approaches were combined with the 146 responses regarding canine
patients for those specialists who reported treating both species
the same way for a total of 202 responses regarding treatment of
hypotensive cats.

718
F I G U R E 6 Cutoff diastolic blood pressure value for initiating
vasopressor therapy in cats among Diplomates of the American
College of Veterinary Emergency and Critical Care
A total of 200 responses were received regarding DBP monitoring in
cats. Seventy-seven respondents (38.5%) would consider using a vaso-
pressor at a pressure of <90 mm Hg. Fifty-eight (29.0%) would treat
when the DBP is <80 mm Hg, 36 (18.0%) when the DBP is <70 mm Hg,
11 (5.5%) when the DBP is <60 mm Hg, and 16 (8.0%) when DBP
is <100 mm Hg. Two respondents (1.0%) stated that they would not use
DBP measurement (Figure 6).
A total of 200 responses were received regarding oscillomet-
ric blood pressure monitoring in cats. One hundred and seven
(53.5%) respondents use MAP value as their treatment trigger
(MAP < 70 mm Hg, n = 15, 7.5%; MAP < 65 mm Hg, n = 43,
21.5%; MAP < 60 mm Hg, n = 49, 24.5%). Only 18 (9.0%) respon-
dents use SAP to determine treatment (SAP < 100 mm Hg, n = 3,
1.5%; SAP < 90 mm Hg, n = 9, 4.5%; SAP < 80 mm Hg, n = 3, 1.5%;
SAP < 70 mm Hg, n = 3, 1.5%). Thirty-two respondents (16.0%) stated
they use a combination of oscillometric MAP and SAP when diagnos-
ing hypotension, and 10 (5.0%) stated they use either a critical MAP or
SAP. Thirty-three (16.5%) respondents stated that they would not use
oscillometric blood pressure measurement (Figure 7).
Of the 202 respondents, 26 (12.9%) stated they did not use DABP
measurement in cats. Most respondents (59.4%, n = 120) chose to treat
based on a direct MAP (MAP < 70 mm Hg, n = 18, 9.0%; MAP < 65 mm
Hg, n = 58, 28.7%; MAP < 60 mm Hg, n = 44, 21.8%). Direct SAP
is used by 25 (12.4%) respondents (SAP < 100 mm Hg, n = 3, 1.5%;
SAP < 90 mm Hg, n = 16, 7.9%; SAP < 80 mm Hg, n = 4, 2.0%;
SAP < 70 mm Hg, n = 2, 1.0%). Twenty-four respondents (11.9%)
stated they use a combination of direct MAP and SAP when diagnos-
ing hypotension, and 7 respondents (3.5%) use either a critical MAP or
SAP (Figure 8).
14764431, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vec.13230 by David Alzate - Universidad Ces , Wiley Online Library on [09/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MURPHY ET AL .
F I G U R E 7 Cutoff oscillometric value for initiating vasopressor
therapy in cats among Diplomates of the American College of
Veterinary Emergency and Critical Care. *Other includes respondents
who indicated that they would use either an SAP or MAP or use a
combination of SAP and MAP. MAP, mean arterial pressure; SAP,
systolic arterial pressure
F I G U R E 8 Cutoff direct arterial blood pressure value for initiating
vasopressor therapy in cats among Diplomates of the American
College of Veterinary Emergency and Critical Care. *Other includes
respondents who indicated that they would use either an SAP or MAP
or use a combination of SAP and MAP. MAP, mean arterial pressure;
SAP, systolic arterial pressure
Twenty-seven (13.4%) respondents would start treatment based
on 1 blood pressure measurement; 175 (86.6%) respondents require
multiple measurements. For respondents that use multiple measure-
ments, 170 clinicians provided an answer regarding how long they
wait between measurements. Most wait 2–5 minutes (44.7%, n = 76)
between readings. Twenty-nine specialists (17.1%) wait 1 minute
between readings, 37 (21.8%) wait 6–10 minutes, 19 (11.2%) wait
11–15 minutes, 4 (2.4%) wait 16–20 minutes, and 5 (2.9%) wait
21–30 minutes.
A total of 201 responses were received regarding the first-choice
vasopressor in cats. Most respondents (83.1%, n = 167) would choose

MURPHY ET AL .
F I G U R E 9 First-choice vasopressor for vasodilatory shock in cats
among Diplomates of the American College of Veterinary Emergency
and Critical Care
norepinephrine as the first-choice vasopressor for the cat described in
the survey. The second most common first-choice drug was dopamine
(14.4%, n = 29). One respondent chose phenylephrine, and 1 respon-
dent chose vasopressin as their first-choice drug (0.5% each). Three
respondents (1.5%) chose “Other,” and all 3 stated that they would
choose epinephrine as their first-choice vasopressor (Figure 9).
In determining response to treatment, 134 (66.3%) respondents
consider an increase in SAP > 10 mm Hg as a positive response, 98
(48.5%) consider an increase in MAP > 10 mm Hg a positive response,
59 (29.2%) consider normalization of SAP a positive response, and 50
(24.8%) consider normalization of MAP a positive response. Twenty-
one respondents (10.4%) stated that they use “Other” parameters to
determine a positive response (either in addition to or in place of one
of the previously mentioned options).
Two hundred and one respondents provided an answer to the ques-
tion regarding how long they wait before evaluating if the response to
the initial drug is adequate. Sixty-four (31.8%) clinicians wait 6–10 min-
utes, 54 (26.9%) wait 11–15 minutes, 30 (14.9%) wait 16–20 minutes,
31 (15.4%) wait 1–5 minutes, 19 (9.5%) wait 21–30 minutes, and 3
(1.5%) wait more than 30 minutes.
If the initial response is deemed inadequate, most respondents
(84.2%, n = 170) stated they would titrate up the first-choice vaso-
pressor to a maximal dose before adding in a second vasopressor. For
these respondents, 169 provided an answer to the question regard-
ing whether they would add in or switch to a second vasopressor if
they reach the maximum dose of the first vasopressor and there is
still an inadequate response. The majority (89.3%, n = 151) stated they
would add in a second vasopressor, while the remainder (10.7%, n = 18)
stated they would switch to another vasopressor. Twenty-nine (14.4%)
respondents stated they would add in a second vasopressor before
reaching the maximum dose of the first vasopressor, and 3 respondents
(1.5%) stated they would switch to a second vasopressor rather than
increasing to a maximum dose of the first vasopressor.
14764431, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vec.13230 by David Alzate - Universidad Ces , Wiley Online Library on [09/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
719
F I G U R E 1 0 Second-choice vasopressor for vasodilatory shock in
cats among Diplomates of the American College of Veterinary
Emergency and Critical Care
A total of 180 respondents stated they would choose to add a
second vasopressor (regardless of whether or not the first drug was
titrated to a maximal dose). The most common second-choice drug was
vasopressin (40.6%, n = 73). The next most common second agent was
dopamine (32.2%, n = 58). Norepinephrine was the second agent of
choice for 24 (13.3%) respondents, and phenylephrine was the second
choice for 4 (2.2%) respondents. Twenty-one respondents (11.7%) indi-
cated that they would choose another vasopressor not listed. Write-in
answers included dobutamine (6.1%, n = 11), epinephrine (5.0%, n = 9),
and esmolol (0.6%, n = 1). Twenty-one clinicians chose to switch to
a different vasopressor, but only 20 provided an answer to the ques-
tion regarding their second-choice vasopressor. Eleven respondents
(55.0%) chose dopamine, 5 (25.0%) chose vasopressin, and 2 (10.0%)
chose norepinephrine. One respondent (5.0 %) chose “Other” and
wrote in epinephrine.
A total of 200 responses regarding second-choice vasopressor in
cats were received. Overall, regardless of whether or not the respon-
dent chose to add in or switch to a second drug, the most common
second-choice drug for cats was vasopressin (39.0%, n = 78), followed
by dopamine (34.5%, n = 69), norepinephrine (13.0%, n = 26), dobu-
tamine (5.5%, n = 11), epinephrine (5.0%, n = 10), phenylephrine (2.5%,
n = 5), and esmolol (0.5%, n = 1) (Figure 10).
4 DISCUSSION
Most respondents of the survey work in an ICU, either exclusively or in
combination with time in an ER. Almost all respondents (97.5%) work in
either a specialty referral practice or university teaching hospital. Most
clinicians (68.5%) indicate that they prescribe vasopressors at least on
a monthly basis. All of the survey respondents are board certified in
Emergency and Critical Care medicine and thus are expected to have

720
a high level of knowledge in treating hypotension and prescribing vaso-
pressors. However, despite similar training there was still significant
disagreement about diagnosis and treatment of hypotension in these
theoretical patients with fluid-refractory vasodilatory shock.
The method of blood pressure measurement used to recognize
hypotension varied widely among respondents. DBP was most con-
sistently used, with only 4 respondents stating they would not use
DBP in dogs (compared to 22 and 21 who would not use oscillomet-
ric and DABP, respectively); this was similar to the pattern seen with
responses for cats. While it is widely accepted that DABP measure-
ment is the gold standard for diagnosing hypotension,15–17 placement
and maintenance of an arterial catheter is technically difficult, has
greater inherent risks, and is not always possible in clinical veteri-
nary patients; this is likely the reason for its less common use. It
is interesting that respondents were less likely to use oscillometric
blood pressure in dogs compared to DBP. Multiple studies have com-
pared various noninvasive blood pressure monitoring techniques to
invasive blood pressure monitoring techniques. While some studies
have shown that there is good agreement between DBP and inva-
sive blood pressure monitoring,18,19 more recent studies have shown
that DBP is unreliable for detecting hypotension in dogs.20–22 Some
reports suggest that oscillometric methods may be more reliable,23,24
but another paper found them to be inaccurate when compared to
direct measurements.25 There are few studies evaluating noninvasive
blood pressure monitoring in cats, but results suggest that both oscil-
lometric and DBP in cats are unreliable.26,27 One study comparing
oscillometric and DBP to direct pressures suggested that oscillometric
methods may be better for measuring SAP, while DBP is better for MAP.
In both cases, however, agreement with direct pressures was poor, and
the authors suggest that indirect methods are better for documenting
trends in blood pressure rather than specific values.27
Respondents showed similar disagreements about what blood pres-
sure cutoffs would prompt them to initiate vasopressor therapy. When
using DBP, most respondents would start vasopressor therapy in dogs
when the value fell below 90 or 80 mm Hg (40.9% or 29.8%, respec-
tively); similar cutoffs were reported for cats. When using oscillometric
or DABP measurements, most respondents use MAP to determine
when to start vasopressors with a similar percentage of respondents
using a cutoff value of <60 mm Hg and <65 mm Hg for both dogs
and cats. This fits with the general definition of hypotension as an
MAP of <60–65 mm Hg; below this level, autoregulation of renal and
cerebral blood flow is lost; therefore, perfusion of these organs is
dependent entirely on systemic blood pressure.28 There is still, how-
ever, much debate as to the optimal blood pressure target when using
vasopressors. One recent retrospective in people showed that MAP
thresholds <85 mm Hg were associated with higher risks for mortal-
ity, acute kidney injury, and myocardial injury.29 Another meta-analysis,
however, found that higher blood pressure targets (75–80 mm Hg)
may increase mortality in patients treated with vasopressors for
more than 6 hours when compared to lower blood pressure tar-
gets (60–65 mm Hg). Additionally, those in the lower blood pressure
target group did not have an increase in adverse events.30 The Sur-
viving Sepsis Campaign (SSC) recommends an initial target of an
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MURPHY ET AL .
MAP > 65 mm Hg in patients requiring vasopressors (strong rec-
ommendation, moderate evidence).31 A survey of physicians in the
European Society of Intensive Care Medicine found that the major-
ity of respondents (70%) targeted an MAP of >60–65 mm Hg.10 Our
results show that veterinary criticalists tend to choose similar MAP val-
ues of <60 or <65 mm Hg for initiating vasopressor therapy in dogs and
cats. There are no current veterinary guidelines to support any given
cutoff value. Additionally, most human guidelines are based on MAP.
Our survey respondents were more likely to state that they would not
use oscillometric or DABP in dogs and cats compared to DBP, suggest-
ing a preference for DBP for diagnosing hypotension in small animals.
DBP is generally thought to best reflect SAP in dogs; however, there is
conflicting evidence as to whether it is more indicative of SAP or MAP
in cats.32 Further studies are warranted to determine the optimal blood
pressure cutoffs for initiation of vasopressor therapy using different
blood pressure monitoring techniques in small animal patients.
The most common drugs used to treat hypotension in both human
and veterinary patients include catecholamines (eg, norepinephrine,
epinephrine, dopamine, phenylephrine) and nonadrenergic vasopres-
sors (eg, vasopressin). The catecholamines work by binding to adren-
ergic receptors, which are divided into 2 major types (α and β), with
at least 9 different subtypes (α1A , α1B , α1D , α2A/D , α2B , α2C , β1 , β2 , and
β3 ).33 Table 1 summarizes the differential effects of commonly used
vasopressors and their actions on these receptors. Dopamine also stim-
ulates specific dopaminergic receptors (D1–5 ) that are located in the
smooth muscle of renal, coronary, splanchnic, and cerebral vascular
beds.34 Vasopressin is a nonadrenergic vasopressor that binds to spe-
cific vasopressin-1 (V1 R) receptors present in vascular smooth muscle,
which causes vasoconstriction when activated.34,35
There was little disagreement about which vasopressor to use as a
first choice, with the overwhelming majority of respondents choosing
norepinephrine for both dogs and cats. Interestingly, a similar survey of
DACVECCs from 2014 showed that there was an approximately 50:50
split between norepinephrine and dopamine as a first-line vasopressor
for both dogs and cats (unpublished data). There is still limited evidence
supporting the use of 1 vasopressor over the other in both human and
veterinary medicine. A 2016 Cochrane Review compared the use of
norepinephrine, epinephrine, dopamine, phenylephrine, vasopressin,
and terlipressin in critically ill patients with shock. No difference in
mortality was found in patients being treated with any of the vaso-
pressors. The incidence of arrhythmias was higher with dopamine as
compared to norepinephrine, but no other significant differences were
found among any of the 6 vasopressors for any measure of morbidity.36
Despite this, the SSC recommends norepinephrine as the first-choice
vasopressor to treat persistent hypotension in septic shock.31 There
are no guidelines for vasopressor choice in veterinary patients. A 2015
review attempted to look at vasopressor choice in animals with sep-
tic shock but concluded that there is insufficient evidence to make
definitive recommendations.37 Clearly, additional studies comparing
different vasoactive drugs are needed in veterinary medicine but, until
then, veterinarians will likely continue to follow human guidelines.
If initial vasopressor therapy did not provide an adequate response,
most respondents (84.5%) stated they would titrate their first-choice
 14764431, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vec.13230 by David Alzate - Universidad Ces , Wiley Online Library on [09/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MURPHY ET AL . 721

TA B L E 1 Receptor activity, cardiopressor effects, and dosages of commonly administered vasopressor drugs

Receptor activity Effect ona

Cardiac Vasomotor Blood
β1 β2 α1 and α2 Contractility Heartrate output tone pressure Dosage
Dobutamine ++ + + ↑↑ ↑ ↑↑ ↓ Variable 5–20 μg/kg/min
Dopamineb ++ + ++ ↑↑ ↑↑ Variable ↑↑ ↑↑ 5–20 μg/kg/min
Epinephrinec +++ +++ +++ ↑↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑↑ 0.05–1 μg/kg/min
Norepinephrine + 0 +++ ↑ Variable Variable ↑↑↑ ↑↑↑ 0.1–2 μg/kg/min
Phenylephrine 0 0 +++ 0 ↓ ↓ ↑↑↑ ↑↑↑ 0.5–5 μg/kg/min
Vasopressin 0 0 0 0 ↓ ↓ ↑↑ ↑↑ 0.5–5 mU/kg/min

Note: Modified with permission from Haskin SC. Catecholamines. In: Silverstein DC, Hopper K, eds. Small Animal Critical Care Medicine. 2nd ed. St. Louis,
MO: Elsevier Saunders; 2015:830. Activity ranges from no activity (0) to maximal activity (+++). Possible cardiopressor effects include a decrease (↓), mild
increase (↑), moderate increase (↑↑), or marked increase (↑↑↑).
a
Effects are estimated for the higher dose ranges.
b
Dose-dependent effects ranging from dopaminergic at low doses, β-agonist at mid doses, and α-agonist at high doses.
c
Dose-dependent effects ranging from β-agonist at low doses, mixed α and β at mid doses, and α-agonist at high doses.39

drug to a maximal dose before adding or switching to a different
vasopressor; most of these respondents (91.7%) chose to add in a
second vasopressor rather than switching to a different drug (8.3%).
The current SSC guidelines recommend adding either vasopressin
or epinephrine to norepinephrine to reach a target MAP or adding
vasopressin to decrease the norepinephrine dose. There are no spe-
cific recommendations regarding when to start a second vasopressor.
According to the guidelines, dopamine should only be used in spe-
cific patients due to its risk of causing tachyarrhythmias. Dobutamine
is recommended in patients with persistent hypotension despite ade-
quate fluid resuscitation and the use of vasopressors.31 In our survey,
vasopressin was the most common (44.2% for dogs; 39.0% for cats)
second-choice vasopressor, which adheres to these guidelines. How-
ever, almost a third (30.7% for dogs; 34.5% for cats) of respondents
chose dopamine as their second-choice vasopressor. The high cost of
vasopressin is likely a significant barrier to its more widespread use in
veterinary medicine. Epinephrine and dobutamine were not listed as
choices in this survey, but respondents wrote these answers in under
“Other” for both cats and dogs. While more research is still needed to
determine the best first- and second-choice vasopressors in veterinary
patients, human guidelines suggest that epinephrine is preferable to
dopamine in refractory hypotension, but only a small number of veteri-
nary criticalists seem to use this in practice. It is possible that a lower
number of respondents chose epinephrine because it was not listed as
a choice and those that did choose it had to write it in. It is also impor-
tant to note that definitive research documenting the risks of dopamine
seen in human patients is absent in the veterinary literature, and it is
possible that this drug is a safe and acceptable alternative for critically
ill small animal patients. Esmolol was also not listed as a choice in the
survey but was written in by 1 respondent for cats. While there is some
evidence that esmolol may be of benefit in a subset of human patients
with vasodilatory shock,38 it is generally not considered to be a vaso-
pressor, and a detailed discussion of its use is beyond the scope of this
paper.
There are several limitations to this study. Only 27.7% of contacted
DACVECCs responded to the survey, thus introducing response bias
as these results only reflect the preferences and practices of those
who chose to respond. Additionally, results were not separated by type
of institution or clinical practice setting, which may influence which
vasopressors are available to clinicians and how they are used. The
nature of the survey also does not necessarily differentiate clinician
preference versus actual practice, which may skew results, especially
for those practices that are limited by cost or feasibility in veterinary
patients. The question regarding determining a positive response to
vasopressor therapy offers normalization of SAP or MAP as a possible
answer, but this is not explicitly defined. Clinicians may have differ-
ent definitions for what normalization means, thus affecting how they
might answer this question. Nevertheless, these survey results suggest
that most veterinary criticalists adhere to published human guidelines
when choosing a first-line vasopressor. However, there is significant
variability in how to measure blood pressure, cutoffs for initiation of
vasopressor use, and choice of second-line vasopressors. Clinical trials
in dogs and cats with vasodilatory shock that examine adverse effects
and outcomes are neded to determine best practice guidelines for use
of vasopressors in critically ill small animals.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
ORCID
Kellyann M. Murphy DVM https://orcid.org/0000-0001-7906-4880
ENDNOTE
a
Survey Gizmo; https://app.surveygizmo.com.
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SUPPORTING INFORMATION
Additional supporting information can be found online in the Support-
ing Information section at the end of this article.
How to cite this article: Murphy KM, Rishniw M, Silverstein
DC. Use of vasopressors for treatment of vasodilatory
hypotension in dogs and cats by Diplomates of the American
College of Veterinary Emergency and Critical Care. J Vet Emerg
Crit Care. 2022;32:714-722.
https://doi.org/10.1111/vec.13230