Template:Vasopressor table: Difference between revisions
(Add MedicationDose SMW annotations for all vasopressors — dosing verified against SSC 2021)
 
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===[[Vasopressors]]===
===[[Vasopressors]]===
''Vasopressors may be initiated peripherally while central access is being obtained — do not delay for central line placement (SSC 2021).''<ref name="SSC2021">Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021;49(11):e1063-e1143.</ref>
{| class="wikitable"
{| class="wikitable"
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! Pressor!! Initial Dose !! Max Dose !! Cardiac Effect !! BP Effect !! [[Arrhythmias]] !! Special Notes
! Pressor !! Initial Dose !! Max Dose !! Cardiac Effect !! BP Effect !! [[Arrhythmias]] !! Special Notes
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| [[Dobutamine]] || 2.5mcg/kg/min || 10-40 mcg/kg/min || mainly inotrope (ß1) || alpha effect minimal || Some HR(ß1) increase. Also Increase SA and AV node fx || Debut Research 1979<ref>Edmund H. Sonnenblick, M.D., William H. Frishman, M.D., and Thierry H. LeJemtel, M.D. Dobutamine: A New Synthetic Cardioactive Sympathetic Amine</ref> Isoproterenol has most Β2 vasodilatory and Β1 HR effects
| [[Dobutamine]] || 2-5 mcg/kg/min || 20 mcg/kg/min (up to 40 in refractory cases)<ref>Unverferth DV, Blanford M, Kates RE, Leier CV. Tolerance to dobutamine after a 72 hour continuous infusion. Am J Med. 1980;69(2):262-6.</ref> || Strong β₁ agonist (+inotrope, +chronotrope); weak β₂ agonist (+vasodilation) || Minimal α effect; '''may decrease''' BP due to β₂ vasodilation || Variable HR effects; can cause tachycardia || Indicated in decompensated systolic [[CHF]] and cardiogenic shock with adequate BP. Not a vasopressor — it is an '''inotrope'''. Must be used with a vasopressor if hypotensive.
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| [[Dopamine]] || 2mcg/kg/min || 20-50 mcg/kg/min || β1 and NorEpi release || α effects if > 20mcg/kg/min || Arrhythmogenic from β1 effects || More adverse events when used in shock compared to Norepi<ref name="soap2">De Backer Daniel et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM 363(9). 779-789</ref>
| [[Dopamine]] || 2-5 mcg/kg/min || 20 mcg/kg/min || β₁ and endogenous norepinephrine release || Mixed α and β effects at all doses; α effects predominate at higher doses || '''Arrhythmogenic''' from β₁ effects || More adverse events (especially arrhythmia) when used in shock compared to norepinephrine<ref name="soap2">De Backer D, et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM. 2010;363(9):779-789.</ref>. SSC 2021 suggests '''against''' dopamine as first-line except in select patients with bradycardia and low risk of tachyarrhythmia.
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| [[Norepinephrine]] || 8-12mcg/min || 30 mcg/min || β1 direct effect || β1 and α1,2 effects || Less arrhythmias than Dopamine<ref  name="soap2"></ref>  || Increases MAP, coronary perfusion pressure, little β2 effects.
| [[Epinephrine]] || 1-10 mcg/min (0.01-0.1 mcg/kg/min) || 0.5 mcg/kg/min || +Inotropy, +chronotropy (β₁) || Low dose: β₂ vasodilation may predominate; high dose: α₁ vasoconstriction predominates || Significant — tachycardia, SVT, VT. Increases myocardial O₂ demand. || '''2nd or 3rd line''' for septic shock (SSC 2021: add after norepinephrine ± vasopressin). '''1st line''' for [[anaphylaxis]] (0.3-0.5 mg IM) and [[cardiac arrest]]. May cause splanchnic vasoconstriction, lactic acidosis, and hyperglycemia.
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|[[Milrinone]] || 50mcg/kg x 10 min || 0.375-75mcg/kg/min || Direct influx of Ca<sup>2+</sup> channels|| Smooth muscle vasodilator ||   || PDE Inhibitor which increases Ca<sup>2+</sup> uptake by sarcolemma. No venodilatory activity
| [[Norepinephrine]] || 2-5 mcg/min (0.01-0.03 mcg/kg/min) || 0.5-1 mcg/kg/min (some sources up to 3.3 mcg/kg/min)<ref>Martin C, Papazian L, Perrin G, et al. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock? Chest. 1993;103(6):1826-31.</ref> || Mild β₁ direct effect (+inotropy) || Strong α₁ and α₂ vasoconstriction; β₁ effect || Less arrhythmogenic than dopamine<ref name="soap2"/> || '''1st line for septic shock''' (SSC 2021)<ref name="SSC2021"/>. Increases MAP primarily via vasoconstriction. Increases coronary perfusion pressure. Minimal β₂ effect.
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| [[Phenylephrine]] || 100-180mcg/min then 40-60mcg/min || 0.4-9 mcg/kg/min || || Alpha agonist  ||   || Long half life
| [[Milrinone]] || 50 mcg/kg IV over 10 min (loading dose often '''omitted''' in acute illness due to hypotension risk) || 0.375-0.75 mcg/kg/min || PDE-3 inhibitor → ↑intracellular cAMP → ↑Ca²⁺ influx → +inotropy || Arteriolar '''and''' venous vasodilator (reduces preload AND afterload) || Less arrhythmogenic than dobutamine || '''Inodilator''' — useful in decompensated HF with elevated afterload, RV failure, or pulmonary hypertension. '''Causes hypotension''' — not a vasopressor; use with a vasopressor if MAP is low. Renally cleared — dose-reduce in CKD.
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| [[Vasopressin]] || Fixed Dose || 0.4 U/min || unknown || increases via ADH peptide ||   || should not be titrated due to ischemic effects
| [[Phenylephrine]] || 100-180 mcg/min, then 40-60 mcg/min || 0.4-9.1 mcg/kg/min || No direct cardiac effect || '''Pure α₁ agonist''' → vasoconstriction || May cause reflex bradycardia || '''Short''' duration of action (5-20 min IV). Use in septic shock '''only if:''' NE causes arrhythmias, cardiac output is high with persistent hypotension, or as salvage when NE + vasopressin have failed.<ref name="SSC2021"/>
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| [[Vasopressin]] || 0.03 U/min (fixed dose) || 0.04 U/min || No direct inotropic or chronotropic effect; possible reflex bradycardia || V₁ receptor agonist → vascular smooth muscle constriction || Minimal || '''2nd line''' in septic shock — add to NE rather than escalating NE (SSC 2021 suggests adding before epinephrine)<ref name="SSC2021"/>. '''Fixed dose''' — generally not titrated. May reduce the risk of atrial fibrillation vs. catecholamine-only regimens.<ref>McIntyre WF, et al. Association of Vasopressin Plus Catecholamine Vasopressors vs Catecholamines Alone With Atrial Fibrillation in Patients With Distributive Shock. JAMA. 2018;319(18):1889.</ref> Avoid dose >0.04 U/min → risk of cardiac and mesenteric ischemia.
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| [[Methylene blue]]<ref>Pasin L, et al. Methylene blue as a vasopressor: a meta-analysis of randomised trials. Crit Care Resusc. 2013;15(1):42-8.</ref> || IV bolus 1-2 mg/kg over 15 min || 1-2 mg/kg/hour (limited data on max duration) || Possible increased inotropy; improves cardiac ATP utilization || Inhibits NO-mediated peripheral vasodilation → increases SVR || Minimal reported || '''Salvage therapy''' for refractory vasodilatory shock unresponsive to catecholamines. '''Contraindicated''' in [[G6PD deficiency]] (hemolytic anemia), [[ARDS]], severe [[pulmonary hypertension]]. Interferes with [[pulse oximetry]] readings (falsely low SpO₂). Avoid with serotonergic drugs (risk of [[serotonin syndrome]]).
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| [[Angiotensin II]] (Giapreza) || 20 ng/kg/min || 40-80 ng/kg/min (max 200 ng/kg/min per label) || No direct cardiac effect || AT₁ receptor agonist → potent arteriolar vasoconstriction; also stimulates aldosterone secretion || Minimal || '''Salvage therapy''' for refractory vasodilatory shock (ATHOS-3 trial)<ref>Khanna A, et al. Angiotensin II for the Treatment of Vasodilatory Shock. N Engl J Med. 2017;377(5):419-430.</ref>. May be particularly useful in patients on ACEi/ARB or with high renin states. Monitor for thrombosis (increased risk reported).
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{{Vasopressor critical care table}}
<div style="display:none">
{{MedicationDose|drug=Norepinephrine|dose=2-5 mcg/min (0.01-0.03 mcg/kg/min), max 0.5-1 mcg/kg/min|route=IV drip|context=1st line vasopressor|indication=Vasopressors|population=Adult|notes=1st line for septic shock (SSC 2021)}}
{{MedicationDose|drug=Epinephrine|dose=1-10 mcg/min (0.01-0.1 mcg/kg/min), max 0.5 mcg/kg/min|route=IV drip|context=2nd/3rd line vasopressor|indication=Vasopressors|population=Adult|notes=1st line for anaphylaxis and cardiac arrest}}
{{MedicationDose|drug=Vasopressin|dose=0.03 U/min (fixed dose), max 0.04 U/min|route=IV drip|context=2nd line vasopressor|indication=Vasopressors|population=Adult|notes=Add to NE rather than escalating NE (SSC 2021)}}
{{MedicationDose|drug=Dopamine|dose=2-5 mcg/kg/min, max 20 mcg/kg/min|route=IV drip|context=Vasopressor|indication=Vasopressors|population=Adult|notes=SSC 2021 suggests against as 1st line; more arrhythmogenic than NE}}
{{MedicationDose|drug=Dobutamine|dose=2-5 mcg/kg/min, max 20 mcg/kg/min|route=IV drip|context=Inotrope|indication=Vasopressors|population=Adult|notes=Inotrope, not a vasopressor; use with vasopressor if hypotensive}}
{{MedicationDose|drug=Phenylephrine|dose=100-180 mcg/min, then 40-60 mcg/min|route=IV drip|context=Pure alpha vasopressor|indication=Vasopressors|population=Adult|notes=Pure alpha-1 agonist; short duration 5-20 min}}
{{MedicationDose|drug=Milrinone|dose=0.375-0.75 mcg/kg/min (loading often omitted)|route=IV drip|context=Inodilator|indication=Vasopressors|population=Adult|notes=Inodilator; causes hypotension; useful in RV failure/pulmonary HTN}}
{{MedicationDose|drug=Methylene blue|dose=1-2 mg/kg IV bolus over 15 min|route=IV|context=Salvage vasopressor|indication=Vasopressors|population=Adult|notes=Salvage for refractory vasodilatory shock; contraindicated in G6PD deficiency}}
{{MedicationDose|drug=Angiotensin II|dose=20 ng/kg/min, max 40-80 ng/kg/min|route=IV drip|context=Salvage vasopressor|indication=Vasopressors|population=Adult|display=Angiotensin II (Giapreza)|notes=Salvage for refractory vasodilatory shock (ATHOS-3 trial)}}
</div>

Latest revision as of 15:50, 20 March 2026

Vasopressors

Vasopressors may be initiated peripherally while central access is being obtained — do not delay for central line placement (SSC 2021).[1]

Pressor Initial Dose Max Dose Cardiac Effect BP Effect Arrhythmias Special Notes
Dobutamine 2-5 mcg/kg/min 20 mcg/kg/min (up to 40 in refractory cases)[2] Strong β₁ agonist (+inotrope, +chronotrope); weak β₂ agonist (+vasodilation) Minimal α effect; may decrease BP due to β₂ vasodilation Variable HR effects; can cause tachycardia Indicated in decompensated systolic CHF and cardiogenic shock with adequate BP. Not a vasopressor — it is an inotrope. Must be used with a vasopressor if hypotensive.
Dopamine 2-5 mcg/kg/min 20 mcg/kg/min β₁ and endogenous norepinephrine release Mixed α and β effects at all doses; α effects predominate at higher doses Arrhythmogenic from β₁ effects More adverse events (especially arrhythmia) when used in shock compared to norepinephrine[3]. SSC 2021 suggests against dopamine as first-line except in select patients with bradycardia and low risk of tachyarrhythmia.
Epinephrine 1-10 mcg/min (0.01-0.1 mcg/kg/min) 0.5 mcg/kg/min +Inotropy, +chronotropy (β₁) Low dose: β₂ vasodilation may predominate; high dose: α₁ vasoconstriction predominates Significant — tachycardia, SVT, VT. Increases myocardial O₂ demand. 2nd or 3rd line for septic shock (SSC 2021: add after norepinephrine ± vasopressin). 1st line for anaphylaxis (0.3-0.5 mg IM) and cardiac arrest. May cause splanchnic vasoconstriction, lactic acidosis, and hyperglycemia.
Norepinephrine 2-5 mcg/min (0.01-0.03 mcg/kg/min) 0.5-1 mcg/kg/min (some sources up to 3.3 mcg/kg/min)[4] Mild β₁ direct effect (+inotropy) Strong α₁ and α₂ vasoconstriction; β₁ effect Less arrhythmogenic than dopamine[3] 1st line for septic shock (SSC 2021)[1]. Increases MAP primarily via vasoconstriction. Increases coronary perfusion pressure. Minimal β₂ effect.
Milrinone 50 mcg/kg IV over 10 min (loading dose often omitted in acute illness due to hypotension risk) 0.375-0.75 mcg/kg/min PDE-3 inhibitor → ↑intracellular cAMP → ↑Ca²⁺ influx → +inotropy Arteriolar and venous vasodilator (reduces preload AND afterload) Less arrhythmogenic than dobutamine Inodilator — useful in decompensated HF with elevated afterload, RV failure, or pulmonary hypertension. Causes hypotension — not a vasopressor; use with a vasopressor if MAP is low. Renally cleared — dose-reduce in CKD.
Phenylephrine 100-180 mcg/min, then 40-60 mcg/min 0.4-9.1 mcg/kg/min No direct cardiac effect Pure α₁ agonist → vasoconstriction May cause reflex bradycardia Short duration of action (5-20 min IV). Use in septic shock only if: NE causes arrhythmias, cardiac output is high with persistent hypotension, or as salvage when NE + vasopressin have failed.[1]
Vasopressin 0.03 U/min (fixed dose) 0.04 U/min No direct inotropic or chronotropic effect; possible reflex bradycardia V₁ receptor agonist → vascular smooth muscle constriction Minimal 2nd line in septic shock — add to NE rather than escalating NE (SSC 2021 suggests adding before epinephrine)[1]. Fixed dose — generally not titrated. May reduce the risk of atrial fibrillation vs. catecholamine-only regimens.[5] Avoid dose >0.04 U/min → risk of cardiac and mesenteric ischemia.
Methylene blue[6] IV bolus 1-2 mg/kg over 15 min 1-2 mg/kg/hour (limited data on max duration) Possible increased inotropy; improves cardiac ATP utilization Inhibits NO-mediated peripheral vasodilation → increases SVR Minimal reported Salvage therapy for refractory vasodilatory shock unresponsive to catecholamines. Contraindicated in G6PD deficiency (hemolytic anemia), ARDS, severe pulmonary hypertension. Interferes with pulse oximetry readings (falsely low SpO₂). Avoid with serotonergic drugs (risk of serotonin syndrome).
Angiotensin II (Giapreza) 20 ng/kg/min 40-80 ng/kg/min (max 200 ng/kg/min per label) No direct cardiac effect AT₁ receptor agonist → potent arteriolar vasoconstriction; also stimulates aldosterone secretion Minimal Salvage therapy for refractory vasodilatory shock (ATHOS-3 trial)[7]. May be particularly useful in patients on ACEi/ARB or with high renin states. Monitor for thrombosis (increased risk reported).
Medication IV Dose (mcg/kg/min) Standard Concentration Final Concentration
Norepinephrine (Levophed) 0.01-2 mcg/kg/min 8 mg in 500 mL D5W 16 mcg/mL
Dopamine 2-20 mcg/kg/min 400 mg in 250 mL D5W 1,600 mcg/mL
Dobutamine 2-20 mcg/kg/min 250 mg in 250 mL D5W 1,000 mcg/mL
Epinephrine 0.01-1 mcg/kg/min 1 mg in 250 mL D5W 4 mcg/mL

Norepinephrine 2-5 mcg/min (0.01-0.03 mcg/kg/min), max 0.5-1 mcg/kg/min IV drip — 1st line for septic shock (SSC 2021) Epinephrine 1-10 mcg/min (0.01-0.1 mcg/kg/min), max 0.5 mcg/kg/min IV drip — 1st line for anaphylaxis and cardiac arrest Vasopressin 0.03 U/min (fixed dose), max 0.04 U/min IV drip — Add to NE rather than escalating NE (SSC 2021) Dopamine 2-5 mcg/kg/min, max 20 mcg/kg/min IV drip — SSC 2021 suggests against as 1st line; more arrhythmogenic than NE Dobutamine 2-5 mcg/kg/min, max 20 mcg/kg/min IV drip — Inotrope, not a vasopressor; use with vasopressor if hypotensive Phenylephrine 100-180 mcg/min, then 40-60 mcg/min IV drip — Pure alpha-1 agonist; short duration 5-20 min Milrinone 0.375-0.75 mcg/kg/min (loading often omitted) IV drip — Inodilator; causes hypotension; useful in RV failure/pulmonary HTN Methylene blue 1-2 mg/kg IV bolus over 15 min IV — Salvage for refractory vasodilatory shock; contraindicated in G6PD deficiency Angiotensin II (Giapreza) 20 ng/kg/min, max 40-80 ng/kg/min IV drip — Salvage for refractory vasodilatory shock (ATHOS-3 trial)

  1. ↑ 1.0 1.1 1.2 1.3 Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021;49(11):e1063-e1143.
  2. ↑ Unverferth DV, Blanford M, Kates RE, Leier CV. Tolerance to dobutamine after a 72 hour continuous infusion. Am J Med. 1980;69(2):262-6.
  3. ↑ 3.0 3.1 De Backer D, et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM. 2010;363(9):779-789.
  4. ↑ Martin C, Papazian L, Perrin G, et al. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock? Chest. 1993;103(6):1826-31.
  5. ↑ McIntyre WF, et al. Association of Vasopressin Plus Catecholamine Vasopressors vs Catecholamines Alone With Atrial Fibrillation in Patients With Distributive Shock. JAMA. 2018;319(18):1889.
  6. ↑ Pasin L, et al. Methylene blue as a vasopressor: a meta-analysis of randomised trials. Crit Care Resusc. 2013;15(1):42-8.
  7. ↑ Khanna A, et al. Angiotensin II for the Treatment of Vasodilatory Shock. N Engl J Med. 2017;377(5):419-430.
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