Vasopressor resident survival guide
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Zaghw, M.D. [2]
Overview
Management
| Norepinephrine | Dopamine | Vasopressin | Phenylephrine | Dobutamine | |
| Mechanism | Mainly predominantα1 agonist (Vasoconstrictive) *some β1 agonist (↑contractility) |
*Mainly predominant β1 agonist (↑ cardiac contractility) * some α1 agonist(Vasoconstrictive) |
*V1 receptor of GIT vasculatures *Antidiuretic effects |
*Pure α1 agonist(Vasoconstrictive) *No β1 |
*Predominant β1 agonist (↑contractility) *β2 arterial smooth muscle (Hypotensive) |
| Indication | *1st line in : *Septic shock *Cardiogenic shock *Undifferentiated shock |
2nd line septic shock | 2nd line septic shock | 1st line Neurogenic shock 3rd-4th line septic shock |
*1st line cardiogenic shock * low output septic shock |
| Dose | 1-30 mcg/min 0.01-0.3mcg/kg/min |
2-20 mcg/min | 0.03 unit/min | 20-300 mcg/kg/min | 2.5-20 mcg/kg/min |
| Complications | Tachyarrhythmia {less β1 effect} ( less than Dopamine ) |
Arrhythmia (more β1) | *Coronary spasm *Splanchnic vasoconstriction |
Reflex bradycardia (only α1) |
Hypotension (β2) |
| Cautions | Arrhythmia | *Not in cardiogenic shock *Arrhythmia *Ischemia induced cardiotoxicity |
*Ischemic heart *Gut ischemia |
*Bradycardia *Heart block |
*Hypotension (add α1 agonist) |
Do's
- Assess the cause of shock
- Always volume fluid resuscitation first
- Norepinephrine in undifferentiated shock.
- Titrate dobutamine according to clinical response slowly ( 2-20 ug/kg/min ) to avoid tachycardia (10% increase from the baseline). The benefit that dobutamine has as minimal effect on myocardial oxygen demand is lost if it is not well titrated.
Don'ts
- Do not start with low dose Dopamine dose to perfuse the kidney.