Vasopressors: Difference between revisions
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==See Also==
==See Also==
*[[Critical care quick reference]]
*[[Critical care quick reference]]
*[[Norepinephrine]]
*[[Dopamine]]
*[[Dobutamine]]
*[[Phenylephrine]]
*[[Vasopressin]]
*[[Epinephrine]]
*[[Milrinone]]


== References ==
== References ==

Revision as of 02:54, 11 June 2015

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.

  • Brain: MAP of 50 mmHg [1]
  • Heart: MAP of 65 mmHg[2]
  • Kidneys: MAP 65-75 mmHg[3]

IV Vasopressor have not been shown to be unsafe when used peripherally[4] If running peripherally perform frequent site check via institutional protocol. [5]

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) [6] Strong ß1 agonist +inotrope +chronotrope, Weak ß2 agonist +weak vasodilatation ) alpha effect minimal HR variable effects. indicated in decompensated systolic HF, Debut Research 1979[7] 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[8]
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) [9] mild β1 direct effect β1 and strong α1,2 effects Less arrhythmias than Dopamine[8] 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[10] 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 when need temporary BP or CO boost
    • Post-intubation hypotension
    • Propofol-induced hypotension
    • A-fib w/ hypotension
      • Easier to convert well-perfused heart

Epinephrine

  • Mix 9mL of NS with 1mL of 1:10,000 epi
    • Now have 10mL of 10mcg/mL
      • Use 0.5-2mL q2-5min (similar to epi drip)
      • Same as 2% lido with epi
        • Ok to give peripherally
  • Onset - 1min
  • Duration - 5-10min

Phenylephrine

  • Pure alpha (no effect on heart)
  • Place 1mL of 10mg/mL vial in 100mL NS
    • Now have 100mcg/mL
    • Draw up 10mL
    • Use 0.5-2mL q2-5min (50-200mcg)
  • Onset - 1min
  • Duration - 20min

See Also

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. ↑ Emcrit Vasopressor basics http://emcrit.org/podcasts/vasopressor-basics/
  3. ↑ 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.
  4. ↑ 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
  5. ↑ Chen J. et al. Extravasation injury associated with low-dose dopamine.. Ann Pharmacother. 1998 May;32(5):545-8
  6. ↑ https://www.ncbi.nlm.nih.gov/pubmed/8449087
  7. ↑ Edmund H. Sonnenblick, M.D., William H. Frishman, M.D., and Thierry H. LeJemtel, M.D. Dobutamine: A New Synthetic Cardioactive Sympathetic Amine
  8. ↑ 8.0 8.1 De Backer Daniel et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM 363(9). 779-789
  9. ↑ https://www.ncbi.nlm.nih.gov/pubmed/15542956
  10. ↑ Pasin L et al. Methylene blue as a vasopressor: a meta-analysis of randomised trials. Crit Care Resusc. 2013 Mar;15(1):42-8.
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