Vasopressors: Difference between revisions
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==Norepinephrine== | ==Norepinephrine== | ||
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===Dosing=== | ===Dosing=== | ||
*Start 2mcg/min | *Start 2mcg/min | ||
**Incr by 1-2mcg/min | **Incr by 1-2mcg/min | ||
**Max dose is 40mcg/min | **Max dose is 40mcg/min | ||
*Replace volume before starting | *Replace volume before starting | ||
===Rate of Titration=== | |||
*Q2-5 min | |||
===Adverse Effects=== | ===Adverse Effects=== | ||
*If extravasates use phentolamine 5-10mg into affected area | *If extravasates use phentolamine 5-10mg into affected area | ||
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*May use in peripheral IV temporarily | *May use in peripheral IV temporarily | ||
**Avoid using in same line as alkaline infusions | **Avoid using in same line as alkaline infusions | ||
===Rate of Titration=== | |||
*Q2-5 min | |||
===Adverse Effects=== | ===Adverse Effects=== | ||
*Low doses: | *Low doses: | ||
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*Low-output heart failure | *Low-output heart failure | ||
*Tricyclic overdose | *Tricyclic overdose | ||
===Primary Receptor=== | |||
* β1 | |||
* β2 | |||
===Relative Effects=== | |||
*↑↑↑SV | |||
*↑↑HR | |||
*↓SVR (transient, from β2 agonism) | |||
===Dosing=== | ===Dosing=== | ||
*2-20mcg/kg/min | *2-20mcg/kg/min | ||
**10mcg works for most | **10mcg works for most | ||
*May use in peripheral IV | *May use in peripheral IV | ||
===Rate of Titration=== | |||
*Q2-5 min | |||
===Adverse Effects=== | ===Adverse Effects=== | ||
* | *Tachyarrhythmias | ||
* | *Myocardial ischemia | ||
* | *Hypotension as β2 effect may result in vasodilation | ||
**Caution if | **Caution if SBP <90 | ||
==Phenylephrine== | ==Phenylephrine== | ||
===Indication=== | ===Indication=== | ||
*Shock | *Neurogenic Shock | ||
===Primary Receptor=== | |||
*α1 | |||
===Relative Effects=== | |||
*↑SVR | |||
*↓HR (reflex bradycardia) | |||
===Dosing=== | ===Dosing=== | ||
*Start 100-200mcg/min then taper down | *Start 100-200mcg/min then taper down | ||
Revision as of 23:26, 8 January 2014
Norepinephrine
Indication
- Septic shock
Primary Receptor
- α1 >> β1
Relative Effects
- ↑↑↑SVR
- ↑HR
- ↑SV
Dosing
- Start 2mcg/min
- Incr by 1-2mcg/min
- Max dose is 40mcg/min
- Replace volume before starting
Rate of Titration
- Q2-5 min
Adverse Effects
- If extravasates use phentolamine 5-10mg into affected area
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
- Bradycardia
- If extravasates use phentolamine
Mechanism of Action
- Alpha agonist
- Vasoconstriction w/ reflex decr HR
- May decrease stroke volume
- Vasoconstriction w/ reflex decr HR
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
- Now have 10mL of 10mcg/mL
- Onset - 1min
- Duration - 5-10min
Phenylephrine
- Pure alpha (no effect on heart)
- Place 1mL of 10mg/mL in 100mL NS
- Draw up 10mL
- Now have 100mcg/mL
- Use 0.5-2mL q2-5min
- Draw up 10mL
- Onset - 1min
- Duration - 20min
Source
- EBmedicine.net
- Tintinalli
- EmCrit Podcast 6