Pharm
Vasopressor
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Vasopressor
, Vasoconstrictor, Push Dose Pressor, Bolus Dose Pressor, Vasopressor Extravasation
See Also
Hypotension
Septic Shock
Background
See specific medications (follow links) for preparation and dosing protocols
Vasopressors are typically used via
Central Line
access
However may be used peripherally for stabilization in first 1-2 hours (see precautions below)
Push Dose Pressors are typically used via
Peripheral IV Access
(see below)
Precautions
Gene
ral
Vasopressors are second-line therapy for
Hypotension
after cause-specific measures
Start with at least 30 ml/kg of crystalloid in
Septic Shock
Replace acute blood loss with blood
Frequently reevaluate volume status, perfusion markers (e.g.
Lactic Acid
) and
Hypotension
response
See
Hypotension
See
Rapid Ultrasound in Shock
Precautions
Peripheral Vasopressor administration
Do not use Vasopressors via unreliable, small or deep peripheral site
Use only larger bore, reliable superficial IVs that can be closely monitored
Avoid peripheral hand IV or
Ultrasound
-guided deep brachial (occult extravasation risk)
Best to transition within first 2 hours to
Central Line
Vasopressor delivery
However, norepinephine may be safely used for 24 hours via large bore, reliable peripheral IV
Monitor peripheral IV closely for extravasation
Peripheral Vasopressor delivery appears safe for short-term use (studies looked at 12-24 hours)
Recent studies have demonstrated
Norepinephrine
peripheral safety
Push Dose Pressors (see below) also appear safe
Ricard (2013) Crit Care Med 4(9): 2108-15 +PMID:23782969 [PubMed]
Cardenas-Garcia (2015) J Hosp Med 10(9): 581-5 +PMID:26014852 [PubMed]
Nguyen (2020) Am J Emerg Med +PMID: 31959524 [PubMed]
Peripheral Vasopressor Extravasation management
Direct others to obtain reliable access (other peripheral IV,
IO Line
,
Central Line
)
Leave infiltrating catheter in place until following measures are completed
Use the infiltrating catheter to withdraw as much infused Vasopressor from the site
Phentolamine Mesylate SQ Immediately (even if skin site has not yet whitened)
Dilute Phentolamine vial (5 mg/ml) in 9 ml
Normal Saline
Inject diluted phentolamine 0.1 to 0.2 mg/kg (up to 10 mg) SQ into extravasation site
Second dose may be needed
Consult plastic surgery
References
Orman and Weingart (2016) EM:Rap 16(5): 12-3
Preparations
Push Dose Pressors (Bolus Dose Pressors)
Indications
Temporizing measure in severe
Hypotension
(MAP <60 mmHg)
Bolus pressors typically via peripheral IV (prior to central access)
Gene
ral
Used initially prior to central
Intravenous Access
Medications are used in diluted form
Both
Epinephrine
and
Phenylephrine
have onset of action within 1 minute
Phenylephrine
duration of action 10-20 minutes
Epinephrine
duration of action 5-10 minutes
Precaution: Dosing errors are common (double check concentration and dose)!
Label all syringes with medication and concentration
Holden (2018) Ann Emerg Med 71(1): 83-92 +PMID:28601272 [PubMed]
Epinephrine
(diluted to 10 mcg/ml)
Epineprhine 10 mcg/ml, give 0.5 to 2 ml (5-20 mcg) every 2-5 minutes as needed
See
Epinephrine
for dilution approach (do not use undiluted cardiac
Epinephrine
)
Intravenous Phenylephrine
Phenylephrine
(diluted to 10 mcg/ml) 0.5 to 2 ml (50-200 mcg) every 2-5 minutes as needed
See
Phenylephrine
for dilution approach (do not use undiluted
Phenylephrine
)
Norepinephrine
Norepinephrine
is typically premixed at 16 mcg/ml (no dilution needed)
Dose: 0.5 to 1 ml (8 to 16 mcg)
Onwochei (2017) Anesth Analg 125(1): 212-8 +PMID:28248702 [PubMed]
References
Swaminathan and Weingart in Herbert (2018) EM:Rap 18(11): 3-4
Preparations
Pressor Infusions - Alpha adrenergic agents (primarily)
Norepinephrine
Indications
Preferred first-line Vasopressor in adults
Receptor Activity
Alpha-1 agonist
Lower beta adrenergic activity
Dosing (adults)
Weight Based (preferred)
Start at 0.05 mcg/kg/min
Unlikely to benefit from titration above 0.3 mcg/kg/min
Non-weight based
Start at 5 mcg/min (some recommend starting at 0.5 to 1.0 ug/min)
Typical dose range: 2 to 30 mcg/min
Effects
Strong Vasoconstrictor
Minimal chronotropic activity
Adverse effects
Reflex
Bradycardia
Tachyarrhythmia
May precipitate
Myocardial Ischemia
or infarction
Epinephrine
Receptor Activity
Alpha-1 agonist
Lower beta adrenergic activity
Dosing
Vasopressor dosing: 1-10 mcg/min
Inotropic dosing: 0.01 to 0.08 mcg/kg/min
Push dose (see above): 5-20 mcg every 2-5 min
ACLS
(pulseless
Arrhythmia
): 1 mg bolus
Effects
Strong inotropy
Strong chronotropy
Adverse effects
May precipitate
Myocardial Ischemia
or infarction
Dopamine
Indications
Has been the preferred first-line Vasopressor in children (but significant risks)
Largely replaced by
Norepinephrine
in adults in U.S.
Theoretically safer than
Norepinephrine
when used peripherally
However
Norepinephrine
is often initially used via a reliable peripheral IV safely
Theoretically with greater renal protection than other Vasopressors
Does not appear to offer any significant benefit over other Vasopressors in renal protection
Receptor Activity
Alpha-1 agonist
Moderate beta adrenergic activity
Low
Dopamine
rgic activity
Dosing
Infusion: 2 to 20 mcg/min
Effects
Precursor to
Norepinephrine
Inotropy and chronotropy at moderate doses
Strong Vasoconstrictor at higher doses
Adverse Effects
Increased risk for
Dysrhythmia
Three fold increased mortality in septic children
Ventura (2015) Crit Care Med 43(11): 2292-302 +PMID: 26323041 [PubMed]
Phenylephrine
Indications
Primarily used as a push-dose pressor (see above), especially by
Anesthesia
Receptor Activity
Exclusively alpha-1 agonist
Dosing
Infusion: 25-200 mcg/min
Push Dose Pressor: 50-200 mcg every 2-5 min prn
Effects
Strong peripheral Vasoconstrictor (with increased
Afterload
)
Minimal chronotropic activity
Adverse effects
Reflex
Bradycardia
Cardiogenic Shock
(avoid use in reduced ejection fraction)
Preparations
Pressor Infusions - Beta adrenergic agents (primarily)
Precautions
Inotropic and chronotropic agents with risk for worsening
Hypotension
Exercise
caution in
Hypotension
Most providers use in combination with a low dose pure Vasopressor (e.g.
Norepinephrine
)
Dobutamine
Receptor Activity
Primarily Beta-1 Agonist
Also activity as a Beta-2 Agonist
Dosing
Infusion: 5-40 mcg/kg/min
Effects
Strong inotropy
Moderate chronotropy
Mild Vasodilation
Adverse effects
Increases myocardial oxygen demand
Arrhythmogenic
Milrinone
Mechanism
PDE inhibitor blocks breakdown of cyclic
Adenosine
monophosphate, sustains
Catecholamine
activity
Receptor Activity
Beta-1 Agonist
Beta-2 Agonist
Dosing
Infusion: 0.125 to 0.5 mcg/kg/min
Adverse Effects
Hypotension
risk (avoid in
Hypovolemia
)
Effects
Strong inotropy, increases
Stroke Volume
Decreases
Afterload
by dilating arterioles
Isoproteronol
Indications
Hypotension
due to
Bradycardia
Receptor Activity
Beta-1 Agonist
Beta-2 Agonist
Dosing
Infusion: 2 to 10 mcg/min
Effects
Strong inotropy
Strong chronotropy
No significant vascular effect (although may decrease
Systemic Vascular Resistance
)
Cardiac Output
not appreciably affected
Preparations
Pressor Infusions - Other sites of activity
Vasopressin
Indications
Adjunct to other Vasopressors (e.g.
Norepinephrine
) in refractory
Hypotension
(especially
Septic Shock
)
Receptor Activity
Exclusively at
Vasopressin
receptors (some on vasculature)
Dosing
Infusion: 0.01 to 0.04 units/min
Adverse effects
Higher doses may be associated with ischemia
Effects
Increases
Systemic Vascular Resistance
while still maintaining CNS and cardiac
Blood Flow
Effective, even in severe acidosis
Resources
EM-Crit Blog (Scott Weingart)
http://emcrit.org/wp-content/uploads/push-dose-pressors.pdf
References
Goldberg (2015) Crit Dec Emerg Med 29(3): 9-19
McCollum in Herbert (2019) EM:Rap 19(7):4-6
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