1. General Considerations
- Fluids first. Vasopressors are less effective and can cause organ hypoperfusion if used before adequate fluid resuscitation. The exception is cardiogenic shock, in which fluids must be used cautiously.
Evidence-based vasopressors:
|
Norepinephrine vs. Dopamine |
Large RCT showed dopamine associated with increased arrhythmias and increased death in cardiogenic shock. Meta-analysis showed dopamine associated with increased mortality in septic shock. |
|
Norepinephrine vs. Epinephrine |
RCT showed no benefit to epinephrine over norepinephrine in septic shock. |
|
Norepinephrine vs. Vasopressin |
VASST study showed no mortality benefit to adding low-dose vasopressin to norepinephrine in septic shock. |
2. Simplified Approach
Always use your clinical judgment!
- Septic shock – norepinephrine.
- Cardiogenic shock – norepinephrine.
- Decompensated heart failure WITHOUT significant hypotension – consider dobutamine.
- Anaphylactic shock – epinephrine IM.
3. Starting Doses
Always consult your local hospital’s pharmacy guidelines. See also Cardiology: Cardiogenic Shock
|
Medication |
Dose |
Receptor |
Notes |
|---|---|---|---|
|
Norepinephrine (Levophed) |
1-30 mcg/min |
α1 > β1 |
First-line in septic and cardiogenic shock. Fewer dysrhythmias than dopamine. |
|
Epinephrine |
0.25-10 mcg/min |
α1 & β |
Alpha effects predominant at doses greater than ~5 mcg/min (but variable). Usually used in cardiac arrest or anaphylaxis, but may be used in septic shock as second or third line agent. |
|
Vasopressin |
0.01-0.04 units/min |
V1 & V2 |
Second line for septic shock, also consider in refractory distributive shock particularly with severe acidosis. Pulmonary vasodilator properties also useful in shock in setting of pulmonary hypertension. Caution: may cause coronary and mesenteric vasoconstriction and decrease cardiac output. |
Keywords: vasopressors, hypotension, norepinephrine, vasopressin, epinephrine
Beale RJ, Hollenberg SM, Vincent JL, et al. Vasopressor and inotropic support in septic shock: an evidence based review. Crit Care Med 2004;32:S455-465.
Bellomo R, Chapman M, Finfer S, et al. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Lancet 2000;356:2139-2143.
De Backer D, Aldecoa C, Njimi H, Vincent JL. Dopamine versus norepinephrine in the treatment of septic shock: a metaanalysis. Crit Care Med 2012;40:725-30.
De Backer D, Devriendt, J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 2010; 362:779.
Myburgh JA, et al. A comparison of epinephrine and norepinephrine in critically ill patients. Intensive Care Med 2008;34:2226-34.
Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med 2008;358:877-87.