Vasopressors: Difference between revisions
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==Background==
==Background==
The goal of vasopressor use is to reach critical organ perfusion pressure.  Estimated required mean arterial pressures (MAP) are listed below.  It is generally safe to aim for a goal map of 65 mmHg.  Vasopressors also promote increased venous return.
*Goal is to reach critical organ perfusion pressure
*Brain: MAP of 50 mmHg <ref>Plöchl, W, D J Cook, T A Orszulak, and R C Daly. 1998. Critical cerebral perfusion pressure during tepid heart operations in dogs. The Annals of thoracic surgery, no. 1. http://www.ncbi.nlm.nih.gov/pubmed/9692450</ref>
**Brain: MAP of 50 mmHg <ref>Plöchl, W, D J Cook, T A Orszulak, and R C Daly. 1998. Critical cerebral perfusion pressure during tepid heart operations in dogs. The Annals of thoracic surgery, no. 1. http://www.ncbi.nlm.nih.gov/pubmed/9692450</ref>
*Heart: MAP of 65 mmHg<ref>Emcrit Vasopressor basics http://emcrit.org/podcasts/vasopressor-basics/</ref>
**Heart: MAP of 65 mmHg
*Kidneys: MAP 65-75 mmHg<ref>Bellomo, Rinaldo, Li Wan, and Clive May. 2008. Vasoactive drugs and acute kidney injury. Critical care medicine, no. 4 Suppl. doi:10.1097/CCM.0b013e318169167f. http://www.ncbi.nlm.nih.gov/pubmed/18382191.</ref>
**Kidneys: MAP 65-75 mmHg<ref>Bellomo, Rinaldo, Li Wan, and Clive May. 2008. Vasoactive drugs and acute kidney injury. Critical care medicine, no. 4 Suppl. doi:10.1097/CCM.0b013e318169167f. http://www.ncbi.nlm.nih.gov/pubmed/18382191.</ref>
*IV Vasopressor have not been shown to be unsafe when used peripherally<ref>Ricard JD. et al. Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Crit Care Med. 2013 Sep;41(9):2108-15</ref> If running peripherally perform frequent site check via institutional protocol. <ref>Chen J. et al. Extravasation injury associated with low-dose dopamine. Ann Pharmacother. 1998 May;32(5):545-8</ref>


IV Vasopressor have not been shown to be unsafe when used peripherally<ref>Ricard JD. et al. Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Crit Care Med. 2013 Sep;41(9):2108-15</ref> If running peripherally perform frequent site check via institutional protocol. <ref>Chen J. et al. Extravasation injury associated with low-dose dopamine.. Ann Pharmacother. 1998 May;32(5):545-8</ref>
==Types==
 
{{Vasopressor table}}
==[[Norepinephrine]]==
 
===Indication===
*Septic shock (1st line)
*Cardiogenic shock:
**If marked hypotension (SBP <70)
**If used with dobutamine
===Primary Receptor===
*α1 >> β1
===Relative Effects===
*↑↑↑SVR
*↑HR
*↑SV
===Dosing===
''Based on Glomerular Filtration Rate [GFR (ml/min)]''
*<10:  0.2mcg/kg/min
*10-40:  0.3mcg/kg/min
*>40-50:  0.4mcg/kg/min
 
*For CVVHD: dose at 0.4mcg/kg/min
*For HD: dose 0.2mcg/kg/min
 
===Rate of Titration===
*Q2-5 min
===Adverse Effects===
*If extravasation occurs use phentolamine 0.1 to 0.2 mg/kg (maximum dose 10 mg) subcutaneous in affected site<ref>ZUCKER G. et al. Treatment of shock and prevention of ischemic necrosis with levarterenol-phentolamine mixtures. Circulation. 1960 Nov;22:935-7.</ref><ref>PELNER L. et al. The problem of levarterenol (levophed) extravasation an experimental study.. Am J Med Sci. 1958 Dec;236(6):755-66</ref>
**Consult plastic/general surgery service to follow the patient and eval for need for intervention<ref>Emcrit peripheral vasopressors http://emcrit.org/podcasts/peripheral-vasopressors-extravasation/</ref>
 
===Notes===
More potent vasoconstrictor than dopamine and phenylephrine.
 
==[[Dopamine]]==
===Indication===
*Hypotension caused by:
**Septic shock
**MI
**Trauma/spinal shock
**Heart failure
===Primary Receptor===
* Low dose: DA, β1
* High dose: DA, α1 >> β1
===Relative Effects===
*Low dose: Natriuresis, ↑↑HR, ↑↑SV
*High dose: ↑SVR and ↑SV
===Contraindication===
*Tachyarrhythmias
===Dosing===
*Low dose:
**1-5 mcg/kg/min - Vasodilation (renal, mesenteric, coronary)
**5-10 mcg/kg/min - predominant β1
*High dose: 10-20 mcg/kg/min - predominant α1
*Titrate to clinical effect
**Use lowest dose possible (prevent tachyphylaxis)
*May use in peripheral IV temporarily
**Avoid using in same line as alkaline infusions
===Rate of Titration===
*Q2-5 min
===Adverse Effects===
*Low doses:
**Hypotension
*High doses:
**Hypertension, ectopic beats
*Tissue necrosis (if extravasates)
**If occurs use phentolamine 5-10mg in affected area
 
==[[Dobutamine]]==
===Indication===
*Cardiogenic shock
*Low-output heart failure
*Tricyclic overdose
===Primary Receptor===
* β1
* β2
===Relative Effects===
*↑↑↑SV
*↑↑HR
*↓SVR (transient, from β2 agonism)
===Dosing===
*2-20mcg/kg/min
**10mcg works for most
*May use in peripheral IV
===Rate of Titration===
*Q2-5 min
===Adverse Effects===
*Tachyarrhythmias
*Myocardial ischemia
*Hypotension as β2 effect may result in vasodilation
**Caution if SBP <90
 
==[[Phenylephrine]]==
===Indication===
*Neurogenic Shock
===Primary Receptor===
*α1
===Relative Effects===
*↑SVR
*↓HR (reflex bradycardia)
===Dosing===
*Start 100-200mcg/min then taper down
**40-60mcg/min works for most
 
===Adverse Effects===
*Baroreceptor-mediated reflex bradycardia
*If extravasates use phentolamine
 
===Notes===
*Use with caution in pts with spinal cord injury-related bradycardia
*Useful for treatment of vasodilatory shock when norepinephrine or dopamine have precipitated tachyarrhythmias
*In pts with ↓LV function, unopposed α1 may lead to decreased CO or myocardial ischemia
**However clinical trials do not support these effects when used in clinically appropriate dose range
 
==[[Vasopressin]]==
===Indication===
*Adjunct for septic shock
===Primary Receptor===
*V1
===Relative Effects===
*↑SVR
*↓HR
===Dosing===
*0.04 units/min
===Rate of Titration===
*Fixed dose (do not titrate)
===Adverse Effects===
*Bradycardia
*Limb ischemia
*Myocardial ischemia
*Splanchnic ischemia
===Notes===
*Adverse effects are dose-dependent
*Acts on V1 receptors leading to ↑vasoconstriction and
↑sensitivity to catecholamines in pts with shock
==[[Epinephrine]]==
===Indication===
*Anaphylaxis
===Primary Receptor===
*β1
*α1
*β2
===Relative Effects===
*↑↑↑HR
*↑↑↑SV
*↑↑↑SVR
*Bronchodilation (β2)
===Dosing===
*Dose-dependent effects:
*1-10 mcg/min - increase HR and SV
*10-20 mcg/min - increase SVR
===Rate of Titration===
*Q2-5 min
===Adverse Effects===
*Tachyarrhythmias
*Myocardial ischemia
*↑Serum lactate
*Splanchnic ischemia
===Notes===
*↑lactate occurs primarily from ↑glycolysis/glycogenolysis within skeletal muscles not tissue hypoperfusion
*Use with caution in pts with CAD
**However clinical trials have not demonstrated worsened outcomes
 
==[[Milrinone]]==
===Indication===
low cardiac output states due to impaired myocardial contractility
 
===Primary Receptor===
*PDE-3 inhibitor
===Relative Effects===
*↑HR
*↑↑↑SV
*↓SVR
===Dosing===
*Normal renal function:
0.25 - 0.75 mcg/kg/min
*Creatinine clearance < 50mL/min, reduce infusion rate
===Rate of Titration===
*Q2H; slower titration rate if renal insufficiency
===Adverse Effects===
*Tachyarrhythmias
*Hypotension
*Myocardial ischemia
===Notes===
*Can use as alternative to dobutamine in pts with cardiogenic shock and on b-blockers
*Causes pulmonary vasodilation, may be good choice in pts with RV failure
*↑cAMP in cardiac myocytes and vascular smooth muscle, thereby ↑HR and ↑SV while decreasing ↓SVR
*Use with caution in pt with renal failure and hypovolemia


==Push Dose Pressors==
==Push Dose Pressors==
*Use when need temporary BP or CO boost
*Use for temporary BP or CO boost
**Post-intubation hypotension
**Post-intubation hypotension
**Propofol-induced hypotension
**Propofol-induced hypotension
**A-fib w/ hypotension
**A-fib with hypotension
***Easier to convert well-perfused heart
***Easier to convert well-perfused heart


===[[Epinephrine]]===
===[[Epinephrine]]===
*Mix 9mL of NS with 1mL of 1:10,000 epi
*α<sub>1</sub>, α<sub>2</sub>, β<sub>1</sub>, β<sub>2</sub> effects
**Now have 10mL of 10mcg/mL
*Inopressor
***Use 0.5-2mL q2-5min (similar to epi drip)
*Increases heart rate and inotropy and vasoconstricts
***Same as 2% lido with epi
*10 cc syringe with 9 cc of NS and draw up 1 mL of 1:10,000 epi (cardiac epinephrine with 10mL of 100 mcg/mL which is 1 mg of epinephrine)
****Ok to give peripherally
**Now have 10mL of 10mcg/mL (1:100,000)
***Use 0.5-2mL (5-20 mcg) every 1-5min (similar to epinephrine drip)
***Can give peripherally since similar concentrations are give subcutaneously with lidocaine with epinephrine (1:100,000)
*Onset - 1min
*Onset - 1min
*Duration - 5-10min
*Duration - 10min
*Effects are usually gone within 5 minutes


===[[Phenylephrine]]===
===[[Phenylephrine]]===
*Pure alpha (no effect on heart)
*Pure α (no effect on heart) potent vasoconstrictor
*Useful in tachycardic patient since no effect on HR and might even decrease from reflex parasympathetic response
*Increase in heart perfusion can improve cardiac output
 
*Place 1mL of 10mg/mL vial in 100mL NS
*Place 1mL of 10mg/mL vial in 100mL NS
**Now have 100mcg/mL
**Now have 100mcg/mL with total bag containing 10 mg of phenylephrine
**Draw up 10mL
**Draw up 10mL from bag with syringe
**Use 0.5-2mL q2-5min (50-200mcg)
**Use 0.5-2mL (50-200mcg) every 1-5 minutes
***Can give peripherally since drug is approved for IM or SQ use
*Onset - 1min
*Onset - 1min
*Duration - 20min
*Duration - 20min
*Effects are usually gone within 5 minutes


== Source ==
===Extravasation Injury===
*Classically norepinephrine drips
*Avoid hand/wrist and ensure peripheral IV quality before starting vasopressors
*May occur with IO placements as well
*Push dose epinephrine and phenylephrine have low chance of causing extravasation injury
*Dermal necrosis<ref>Phentolamine Mysylate for Injection - Dosage and Administration. http://www.rxlist.com/phentolamine-mesylate-for-injection-drug/indications-dosage.htm.</ref>:
**Prevention - phentolamine mesylate 10mg into each liter of norepinephrine solution (pressor effect is not changed)
**Treatment - 5mg phentolamine in 10 cc of NS injected into area of extravasation
 
==See Also==
*[[Critical care quick reference]]
 
==External Links==
*[http://emcrit.org/podcasts/vasopressor-basics/ EMCrit Podcast - Vasopressor Basics]
*[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5052865/pdf/ceem-15-010.pdf Push-dose pressors for immediate
blood pressure control]
 
==References==
<references/>
<references/>
*EmCrit Podcast 6
 
[[Category:Drugs]]
[[Category:Pharmacology]]
[[Category:Airway/Resus]]
[[Category:Critical Care]]

Revision as of 11:28, 14 August 2017

Background

  • Goal is to reach critical organ perfusion pressure
    • Brain: MAP of 50 mmHg [1]
    • Heart: MAP of 65 mmHg
    • Kidneys: MAP 65-75 mmHg[2]
  • IV Vasopressor have not been shown to be unsafe when used peripherally[3] If running peripherally perform frequent site check via institutional protocol. [4]

Types

Vasopressors

Pressor Initial Dose Max Dose Cardiac Effect BP Effect Arrhythmias Special Notes
Dobutamine 3-5 mcg/kg/min 5-15 mcg/kg/min (as high as 200) [5] Strong ß1 agonist +inotrope +chronotrope, Weak ß2 agonist +weak vasodilatation ) alpha effect minimal HR variable effects. indicated in decompensated systolic HF, Debut Research 1979[6] Isoproterenol has most Β2 vasodilatory and Β1 HR effects
Dopamine 2 mcg/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[7]
Epinepherine 0.1-1 mcg/kg/min + inotropy, + chronotropy
Norepinephrine 0.2 mcg/kg/min 0.2-1.3 mcg/kg/min (5mcg/kg/min) [8] mild β1 direct effect β1 and strong α1,2 effects Less arrhythmias than Dopamine[7] First line for sepsis. Increases MAP with vasoconstriction, increases coronary perfusion pressure, little β2 effects.
Milrinone 50 mcg/kg x 10 min 0.375-75 mcg/kg/min Direct influx of Ca2+ channels Smooth muscle vasodilator PDE Inhibitor which increases Ca2+ uptake by sarcolemma. No venodilatory activity
Phenylephrine 100-180 mcg/min then 40-60 mcg/min 0.4-9 mcg/kg/min Alpha agonist Long half life
Vasopressin Fixed Dose 0.01 to 0.04 U/min unknown increases via ADH peptide should not be titrated due to ischemic effects
Methylene blue[9] IV bolus 2 mg/kg over 15 min 1-2 mg/kg/hour Possible increased inotropy, cardiac use of ATP Inhibits NO mediated peripheral vasodilation Don't use in G6PD deficiency, ARDS, pulmonary hypertension
Medication IV Dose (mcg/kg/min) Concentration
Norepinephrine (Levophed) 0.1-2 mcg/kg/min 8mg in 500mL D5W
Dopamine 2-20 mcg/kg/min 400mg in 250 D5W
Dobutamine 2-20 mcg/kg/min 250mg in 250 mg D5W
Epinephrine 0.1-1 mcg/kg/min 1mg in 250 D5W

Push Dose Pressors

  • Use for temporary BP or CO boost
    • Post-intubation hypotension
    • Propofol-induced hypotension
    • A-fib with hypotension
      • Easier to convert well-perfused heart

Epinephrine

  • α1, α2, β1, β2 effects
  • Inopressor
  • Increases heart rate and inotropy and vasoconstricts
  • 10 cc syringe with 9 cc of NS and draw up 1 mL of 1:10,000 epi (cardiac epinephrine with 10mL of 100 mcg/mL which is 1 mg of epinephrine)
    • Now have 10mL of 10mcg/mL (1:100,000)
      • Use 0.5-2mL (5-20 mcg) every 1-5min (similar to epinephrine drip)
      • Can give peripherally since similar concentrations are give subcutaneously with lidocaine with epinephrine (1:100,000)
  • Onset - 1min
  • Duration - 10min
  • Effects are usually gone within 5 minutes

Phenylephrine

  • Pure α (no effect on heart) potent vasoconstrictor
  • Useful in tachycardic patient since no effect on HR and might even decrease from reflex parasympathetic response
  • Increase in heart perfusion can improve cardiac output
  • Place 1mL of 10mg/mL vial in 100mL NS
    • Now have 100mcg/mL with total bag containing 10 mg of phenylephrine
    • Draw up 10mL from bag with syringe
    • Use 0.5-2mL (50-200mcg) every 1-5 minutes
      • Can give peripherally since drug is approved for IM or SQ use
  • Onset - 1min
  • Duration - 20min
  • Effects are usually gone within 5 minutes

Extravasation Injury

  • Classically norepinephrine drips
  • Avoid hand/wrist and ensure peripheral IV quality before starting vasopressors
  • May occur with IO placements as well
  • Push dose epinephrine and phenylephrine have low chance of causing extravasation injury
  • Dermal necrosis[10]:
    • Prevention - phentolamine mesylate 10mg into each liter of norepinephrine solution (pressor effect is not changed)
    • Treatment - 5mg phentolamine in 10 cc of NS injected into area of extravasation

See Also

External Links

blood pressure control]

References

  1. ↑ Plöchl, W, D J Cook, T A Orszulak, and R C Daly. 1998. Critical cerebral perfusion pressure during tepid heart operations in dogs. The Annals of thoracic surgery, no. 1. http://www.ncbi.nlm.nih.gov/pubmed/9692450
  2. ↑ Bellomo, Rinaldo, Li Wan, and Clive May. 2008. Vasoactive drugs and acute kidney injury. Critical care medicine, no. 4 Suppl. doi:10.1097/CCM.0b013e318169167f. http://www.ncbi.nlm.nih.gov/pubmed/18382191.
  3. ↑ Ricard JD. et al. Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Crit Care Med. 2013 Sep;41(9):2108-15
  4. ↑ Chen J. et al. Extravasation injury associated with low-dose dopamine. Ann Pharmacother. 1998 May;32(5):545-8
  5. ↑ https://www.ncbi.nlm.nih.gov/pubmed/8449087
  6. ↑ Edmund H. Sonnenblick, M.D., William H. Frishman, M.D., and Thierry H. LeJemtel, M.D. Dobutamine: A New Synthetic Cardioactive Sympathetic Amine
  7. ↑ 7.0 7.1 De Backer Daniel et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM 363(9). 779-789
  8. ↑ https://www.ncbi.nlm.nih.gov/pubmed/15542956
  9. ↑ Pasin L et al. Methylene blue as a vasopressor: a meta-analysis of randomised trials. Crit Care Resusc. 2013 Mar;15(1):42-8.
  10. ↑ Phentolamine Mysylate for Injection - Dosage and Administration. http://www.rxlist.com/phentolamine-mesylate-for-injection-drug/indications-dosage.htm.
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