Vasopressors

Vasopressors

Vasopressor Dosing1

Drug Initial Dose Typical Dose Titration q5-15min Weaning q5-15min
Epinephrine 0.02-0.05 mcg/kg/min 0.005-0.2 mcg/kg/min 0.02-0.05 mcg/kg/min 0.02-0.05 mcg/kg/min
Norepinephrine 0.01-0.04 mcg/kg/min 0.04-1 mcg/kg/min 0.02-0.04 mcg/kg/min 0.02-0.04 mcg/kg/min
Dopamine 5-10 (inotropic)
> 10 mcg/kg/min (inopressor)		 2-20 mcg/kg/min 2-5 mcg/kg/min 1 mcg/kg/min
Phenylephrine 0.1-0.3 mcg/kg/min 0.1-1.5 mcg/kg/min 0.2-0.4 mcg/kg/min 0.2-0.4 mcg/kg/min
Vasopressin 0.01-0.04 U/min 0.01-0.04 U/min No titration No weaning
Dobutamine 2.5-5 mcg/kg/min 2.5-10 mcg/kg/min 2.5-5 mcg/kg/min
Alter based on CO/CI or SVO2		 2.5-5 mcg/kg/min
Milrinone 0.25 mcg/kg/min 0.25-0.75 mcg/kg/min Alter based on CO/CI or SVO2 No weaning

Vasopressor Classification2

Drug Classification Note
Epinephrine Inopressor Can bump lactate d/t β stimulation
Norepinephrine Inopressor Good 1st line choice in almost all situations
Dopamine Inopressor Increased mortality in comparison to NE
Phenylephrine Vasopressor  
Vasopressin Vasopressor No pulmonary constriction
Dobutamine Inodilator Increased myocardial O2 demand d/t chronotropy
Milrinone Inodilator Long t1/2 removing need for weaning

Vasopressor Hemodynamic Effects2

Drug HR Inotropy Vasoconstriction Vasodilation Dopaminergic
Epinephrine ++++ ++++ ++++ +++ 0
Norepinephrine + ++ ++++ 0 0
Dopamine (Inotropy)
Dopamine (Inopressor)		 +
++		 +
++ - +++		 0
++ - +++		 +
0		 ++++
++
Phenylephrine 0 0 +++ 0 0
Vasopressin 0 0 ++++ 0 0
Dobutamine ++ +++ - ++++ 0 ++ 0
Milrinone + +++ 0 ++ 0

Vasopressor Receptor Specificity3

Drug α-1 β-1 β-2 Other
Epinephrine +++++ ++++ +++ -
Norepinephrine +++++ +++ ++ -
Dopamine +++ ++++ ++ DA
Phenylephrine +++++ 0 0 -
Vasopressin 0 0 0 V1 (vasoconstriction)
V2 (renal tubules)
Dobutamine + +++++ +++ -
Milrinone 0 0 0 PDE-3

Push-Dose EPI 4

Mixing

  1. 9mL NS in 10mL syringe
  2. Add 1 mL (100mcg) cardiac epinephrine (0.1mg/mL)
    • Caution: above is for 1mg/10mL (0.1mg/mL) premix syringes, EPI vials are 1mg/1mL
  3. Resulting solution is 100mcg/10mL (10mcg/mL) Epinephrine

Admin

0.5-2mL (5-20 mcg) Q2-5min PRN of above solution

Doses last ≈ 10min

If mixing not possible, give 0.5mL dose of pure cardiac epi (50mcg)

DO NOT ADMINISTER 1mg EPI TO INDIVIDUALS NOT IN CARDIAC ARREST

References

  1. Jentzer JC, Coons JC, Link CB, Schmidhofer M. Pharmacotherapy Update on the Use of Vasopressors and Inotropes in the Intensive Care Unit. Journal of Cardiovascular Pharmacology and Therapeutics. 2015;20(3):249-260. doi:10.1177/1074248414559838 ↩

  2. Hollenberg SM. Vasoactive Drugs in Circulatory Shock. American Journal of Respiratory and Critical Care Medicine. 2011;183(7):847-855. doi:10.1164/rccm.201006-0972CI ↩ ↩2

  3. Overgaard CB, Džavík V. Inotropes and Vasopressors: Review of Physiology and Clinical Use in Cardiovascular Disease. Circulation. 2008;118(10):1047-1056. doi:10.1161/CIRCULATIONAHA.107.728840 ↩

  4. Weingart S. Push-dose pressors for immediate blood pressure control. Clinical and Experimental Emergency Medicine. 2015;2(2):131-132. doi:10.15441/ceem.15.010 ↩

Author: Corbin Cox
Created: 2018-12-4
Last Updated: 2018-12-4