Vasopressors and

Inotropes
Critical Care Lecture Series
ICU
Objectives
 What are the different classes of shock and
give examples of each.
 Discuss how to investigate and the
management principles behind each of the
causes of shock.
 What are the different crystalloids and colloids
available for resuscitation?
 Have knowledge of the mechanism of action of
commonly used vasopressors and inotropes,
including dopamine, dobutamine, milnerone,
levophed, phenylephrine, epinephrine,
vasopressin
 Discuss adverse events associated with the
above agents.
ICU
Is My Patient in Shock?

 Definition of shock
 Inadequate end organ perfusion leading
to inadequate oxygen delivery
 N.B. a patient in shock does not have
to be hypotensive
ICU
 Treatment of Shock
ICU

 Basic Resuscitation:
ABCDE’s
 A: Airway establishment
 B: Breathing: control WOB
 C(a): Circulation Optimization
 C(b): Control O2 consumption
 D: Delivery of O2 adequately
 E Extraction of O2
ICU
Fluid resuscitation

 Very important….
 Therapy with least detrimental effects
 Fluid therapy may be beneficial in any
type of shock
 Even cardiogenic shock/pulmonary
edema
ICU
Fluid Resusitation

 Must “test the patient”

 Give volume and look for
response/improvement
 Always start with NS of RL
 ? Need blood
 Must always look for the effect of
treatment
 Re-evaluate patient after fluid
 If no improvement, and no adverse effects,
repeat
 If adverse effect, needs inotropes/vasopressor
if still in shock
 Too much: pulmonary edema (O2 sats)
ICU
A: Airway establishment

Indications for intubation:

1. Failure of oxygenation or ventilation
2. Failure to protect airway
3. Condition present or procedure needed
that will require intubation

“shock” is an indication for intubation

Hypotension common after intubation
ICU
B: Breathing: control WOB

 Respiratory muscles are significant

consumers of oxygen
 Control will allow better O2 delivery
to other tissues
 Sedation after intubation
 C(a): Circulation
ICU
Optimization
 Most causes of shock require some
volume re-expansion – even
cardiogenic shock
- Starling curve
 Crystalloid as good as colloid
 Vasopressors ineffective if
hypovolemic
 “double edged sword”
 C(b): Control O2
ICU
consumption
 Reduce hyper-adrenergic state
 Analgesia/sedation/muscle relaxation
 temperature
ICU
D: Delivery of O2 adequately

 Follow sats (keep > 92%)

 ? Transfusion (Hbg >80-100)
 Lactate
 SmvO2
ICU
E: Extraction of O2

 O2 must get from lungs to Hbg to

tissues
 O2 extraction important in some
types of shock
 Cyanide, MetHbg, SEPSIS
ICU
ABCDE’s: Summary
 A: Airway establishment: 02,biPap, ETT

 B: Breathing: control WOB: Sedation, analgesia

 C(a): Circulation Optimization: fluids, inotropes,

pressors

 C(b): Control O2 consumption: sedation, temp

control, seizure control

 D: Delivery of O2 adequately: Hbg, fluid, pressor,

inotropes

 E: Extraction of O2: R/O cyanide, metHbg, sepsis

ICU
Vasopressors

 Many different pressors/inotropes

 Need to understand how they work to use
effectively
 If choose wrong one, or use
inappropriately, can harm the patient
 Adrenergic precipitation of arrhythmias
 Drive the heart too fast resulting in decreased
filling time and decreased stroke volume
 Vasoconstriction of splachnic circulation and
coronary arteries
 Inotropes may make certain patients
hypotensive
ICU
Vasopressors

 β1 agonist/stimulation: chronitropic,
inotropic
 β2 agonist/stimulation: vasodilation,
bronchodilation
 α: vasoconstriction
 D: increases renal blood flow
ICU Vasopressors and inotropes:
the chart (everything you need to know)

Normal Need CO Need nothing

Blood
pressure

Low Need BP and Need BP

CO
Low Normal

Cardiac Output
ICU
Dopamine

 Dopaminergic, Beta, Alpha: ranges ?

 Dopa: 1-5 ug/kg/min
 ? Renal flow
 Beta: 5-10 ug/kg/min
 Inoptropy/chronotropy
 Alpha: >10 ug/kg/min
 Vasoconstriction
 Major use: increasing HR, ? bp
ICU
Dobutamine

 Beta (little alpha)

 Inotropic/chronotropic
 2-20 ug/kg/min
 Major use: Systolic dysfunction
 Caveat: can/will decrease MAP
ICU
Milrinone
 Used as an inotrope
 Mechanism of Action
 Phosphodiesterase inhibitor
 decrease the rate of cyclic AMP degradation
 increase in cyclic AMP concentration leads to enhanced calcium influx
into the cell, a rise in cell calcium concentration, and increased
contractility
 Side Effects
 can also cause vasodilatation but tends to have less chronotropy than
dobutamine
 Onset of action
 5-15 minutes
 Duration
 Half life of approximately 2 hours (so its gonna last a while
 Dose
 Loading dose: 50 mcg/kg administered over 10 minutes followed by
0.375 mcg/kg/minute
ICU
Phenylepherine

 Pure alpha agonist

 Vasoconstrictor with no effect on
inotropy/chronotropy
 0.2-3.0 ug/kg/min
 Major use: non-cardiogenic
hypotension
ICU
Norepinepherine

 Alpha and Beta

 0.02-3.0 ug/kg/min
 Major Use: when you need A&B
 ? Drug of choice for septic shock
ICU
Epinepherine

 Alpha and Beta

 0.01 – 1.0 ug/kg/min
 Major Use: when you need A&B
 resuscitation
 Vasopressors and inotropes
ICU

Normal Dobutamine nothing

Blood Milrinone
Dopamine
pressure Phenylepherine
Levophed
Low Epinepherine Levophed
Or
Dobutamine/phenyl
(dopamine)
Low Normal

Cardiac Output
ICU
 Overview of the
ICU Management of Shock
ICU
Case Study

 65 yo male presents to ED
 Complaining of cough and feeling
very unwell
 HR 120, BP 100/60, RR 30, temp 39
 Is this patient in shock?
 What investigations
 What treatment would you start?
ICU
Case Study

 The patient’s BP drops to 90/50, what

would you do now?
 Would you start pressors? Which one?
ICU
Case Study

 The patient is on 0.8ug/kg/min of

levophed through a femoral line. Why
might the patient not be responding
to the vasopressors? What
measurement would be helpful in
improving this man’s MAP?
ICU
Case Study

 The patient has been resuscitated,

now has a BP of 110/90. HR 65. His
JVP is 12. His lactate continues to rise
however. He is also anuric. Is this
patient in shock? What is your
management now?
ICU
Summary

 Shock can be the consequence of

decreased SVR, decreased CO or both.
 Management of shock should be tailored to
the physiologic state of the patient of the
patient.
 Drugs are available to augment SVR, HR,
afterload and contractility.
 Remember to optimize preload and
consider the oxygen carrying capacity of
the blood.