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Vasopressors
From WikEM
(Redirected from Pressors)
Contents
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 mmHgScript errorScript error[citation needed]
- 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 | 2.5 mcg/kg/min | 10-40 mcg/kg/min | mainly inotrope (ß1) | alpha effect minimal | Some HR(ß1) increase. Also Increase SA and AV node fx | Debut Research 1979[5] 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[6] |
| Epinepherine | 0.1-1 mcg/kg/min | |||||
| Norepinephrine | 8-12 mcg/min | 30 mcg/min | β1 direct effect | β1 and α1,2 effects | Less arrhythmias than Dopamine[6] | Increases MAP, 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 | 0.4 U/min | unknown | increases via ADH peptide | should not be titrated due to ischemic effects | |
| Methylene blue[7] | 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 with 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 epinephrine 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 vial in 100mL NS
- Now have 100mcg/mL
- Draw up 10mL
- Use 0.5-2mL q2-5min (50-200mcg)
- Onset - 1min
- Duration - 20min
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[8]:
- 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
References
- ↑ 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
- ↑ 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.
- ↑ 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
- ↑ Chen J. et al. Extravasation injury associated with low-dose dopamine.. Ann Pharmacother. 1998 May;32(5):545-8
- ↑ Edmund H. Sonnenblick, M.D., William H. Frishman, M.D., and Thierry H. LeJemtel, M.D. Dobutamine: A New Synthetic Cardioactive Sympathetic Amine
- ↑ 6.0 6.1 De Backer Daniel et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM 363(9). 779-789
- ↑ Pasin L et al. Methylene blue as a vasopressor: a meta-analysis of randomised trials. Crit Care Resusc. 2013 Mar;15(1):42-8.
- ↑ Phentolamine Mysylate for Injection - Dosage and Administration. http://www.rxlist.com/phentolamine-mesylate-for-injection-drug/indications-dosage.htm.
