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Vasopressors and inotropes in treatment of acute hypotensive states and shock: Adult dose and selected characteristics

Vasopressors and inotropes in treatment of acute hypotensive states and shock: Adult dose and selected characteristics
Agent United States trade name Initial dose Usual maintenance dose range Range of maximum doses used in refractory shock Role in therapy and selected characteristics
Vasopressors (alpha-1 adrenergic)
Norepinephrine (noradrenaline) Levophed

5 to 15 mcg/minute (0.05 to 0.15 mcg/kg/minute)

Cardiogenic shock: 0.05 mcg/kg/minute

2 to 80 mcg/minute (0.025 to 1 mcg/kg/minute)

Cardiogenic shock: 0.05 to 0.4 mcg/kg/minute
80 to 250 mcg/minute (1 to 3.3 mcg/kg/minute)
  • Initial vasopressor of choice in septic, cardiogenic, and hypovolemic shock.
  • Wide range of doses utilized clinically.
  • Must be diluted; eg, a usual concentration is 4 mg in 250 mL of D5W or NS (16 micrograms/mL).
Epinephrine (adrenaline) Adrenalin 1 to 15 mcg/minute (0.01 to 0.2 mcg/kg/minute) 1 to 40 mcg/minute (0.01 to 0.5 mcg/kg/minute) 40 to 160 mcg/minute (0.5 to 2 mcg/kg/minute)
  • Initial vasopressor of choice in anaphylactic shock.
  • Typically an add-on agent to norepinephrine in septic shock when an additional agent is required to raise MAP to target and occasionally an alternative first-line agent if norepinephrine is contraindicated.
  • Increases heart rate; may induce tachyarrhythmias and ischemia.
  • For inotropy, doses in the higher end of the suggested range is needed.
  • Elevates lactate concentrations during initial administration (ie, may preclude use of lactate clearance goal); may decrease mesenteric perfusion.
  • Must be diluted; eg, a usual concentration is 1 mg in 250 mL D5W (4 micrograms/mL).
Phenylephrine Neo-Synephrine, Vazculep 40 to 160 mcg/minute until stabilized (alternatively, 0.5 to 2 mcg/kg/minute) 20 to 400 mcg/minute (0.25 to 5 mcg/kg/minute) 80 to 730 mcg/minute (1.1 to 9.1 mcg/kg/minute)
  • Pure alpha-adrenergic vasoconstrictor.
  • May be considered when tachyarrhythmias preclude use of norepinephrine.
  • Alternative vasopressor for patients with septic shock who: (1) develop tachyarrhythmias on norepinephrine, epinephrine, or dopamine, (2) have persistent shock despite use of two or more vasopressor/inotropic agents including vasopressin (salvage therapy), or (3) high cardiac output with persistent hypotension.
  • May decrease stroke volume and cardiac output in patients with cardiac dysfunction.
  • May be given as bolus dose of 50 to 100 mcg to support blood pressure during rapid sequence intubation.
  • Must be diluted. The usual concentration is 10 mg in 250 mL D5W or NS (40 mcg/mL). Others include the following based upon volume status: 10 mg in 500 mL (20 mcg/mL) of D5W or NS, 50 mg in 500 mL (100 mcg/mL) of NS, 100 mg in 500 mL (200 mcg/mL) of NS, or 100 mg in 250 mL (400 mcg/mL) of NS.
Dopamine Inotropin 2 to 5 mcg/kg/minute 2 to 20 mcg/kg/minute 20 mcg/kg/minute
  • An alternative to norepinephrine in septic shock in highly selected patients (eg, with absolute or relative bradycardia and a low risk of tachyarrhythmias).
  • More adverse effects (eg, tachycardia, arrhythmias particularly at doses ≥20 mcg/kg/minute) and less effective than norepinephrine for reversing hypotension in septic shock.
  • Lower doses (eg, 1 to 3 mcg/kg/minute) should not be used for renal protective effect and can cause hypotension during weaning.
  • Must be diluted (eg, a usual concentration is 400 mg in 250 mL D5W [1.6 mg/mL] or 800 mg in 250 mL D5W [3.2 mg/mL]); use of a commercially available pre-diluted solution is preferred.
Antidiuretic hormone
Vasopressin (arginine-vasopressin) Pitressin, Vasostrict 0.03 units/minute 0.01 to 0.04 units/minute (not titrated) Doses >0.04 units/minute can cause cardiac ischemia and should be reserved for salvage therapy
  • Add-on to norepinephrine to raise blood pressure to target MAP or decrease norepinephrine requirement. Not recommended as a replacement for a first-line vasopressor.
  • Pure vasoconstrictor; may decrease stroke volume and cardiac output in myocardial dysfunction or precipitate ischemia in coronary artery disease.
  • Must be diluted; eg, a usual concentration is 25 units in 250 mL D5W or NS (0.1 units/mL).
Inotrope (beta1 adrenergic)
Dobutamine Dobutrex Usual: 2 to 5 mcg/kg/minute (range: 0.5 to 5 mcg/kg/minute; lower doses for less severe cardiac decompensation) 2 to 10 mcg/kg/minute 20 mcg/kg/minute
  • Initial agent of choice in cardiogenic shock with low cardiac output and maintained blood pressure.
  • Add-on to norepinephrine for cardiac output augmentation in septic shock with myocardial dysfunction (eg, in elevated left ventricular filling pressures and adequate MAP) or ongoing hypoperfusion despite adequate intravascular volume and use of vasopressor agents.
  • Increases cardiac contractility and rate; may cause hypotension and tachyarrhythmias.
  • Must be diluted; a usual concentration is 250 mg in 500 mL D5W or NS (0.5 mg/mL); use of a commercially available pre-diluted solution is preferred.
Inotrope (nonadrenergic, PDE3 inhibitor)
Milrinone Primacor 0.125 to 0.25 mcg/kg/minute 0.125 to 0.75 mcg/kg/minute 0.75 mcg/kg/minute
  • Alternative for short-term cardiac output augmentation to maintain organ perfusion in cardiogenic shock refractory to other agents.
  • Increases cardiac contractility and modestly increases heart rate at high doses; may cause peripheral vasodilation, hypotension, and/or ventricular arrhythmia.
  • Renally cleared; dose adjustment in renal impairment needed.
  • Must be diluted; eg, a usual concentration is 40 mg in 200 mL D5W (200 micrograms/mL); use of a commercially available pre-diluted solution is preferred.
  • All doses shown are for intravenous (IV) administration in adult patients. The initial doses shown in this table may differ from those recommended in immediate post-cardiac arrest management (ie, advanced cardiac life support). For details, refer to the UpToDate topic review of post-cardiac arrest management in adults, section on hemodynamic considerations.
  • Vasopressors can cause life-threatening hypotension and hypertension, dysrhythmias, and myocardial ischemia. They should be administered by use of an infusion pump adjusted by clinicians trained and experienced in dose titration of intravenous vasopressors using continuous noninvasive electronic monitoring of blood pressure, heart rate, rhythm, and function. Hypovolemia should be corrected prior to the institution of vasopressor therapy. Reduce infusion rate gradually; avoid sudden discontinuation.
  • Vasopressors can cause severe local tissue ischemia; central line administration is preferred. When a patient does not have a central venous catheter, vasopressors can be temporarily administered in a low concentration through an appropriately positioned peripheral venous catheter (ie, in a large vein) for less than 24 hours. The examples of concentrations shown in this table are useful for peripheral (short-term) or central line administration. Closely monitor catheter site throughout infusion to avoid extravasation injury. In event of extravasation, prompt local infiltration of an antidote (eg, phentolamine) may be useful for limiting tissue ischemia. Stop infusion and refer to extravasation management protocol.
  • Vasopressor infusions are high-risk medications requiring caution to prevent a medication error and patient harm. To reduce the risk of making a medication error, we suggest that centers have available protocols that include steps on how to prepare and administer vasopressor infusions using a limited number of standardized concentrations. Examples of concentrations and other detail are based on recommendations used at experienced centers; protocols can vary by institution.
D5W: 5% dextrose water; MAP: mean arterial pressure; NS: 0.9% saline.
Prepared with data from:
  1. Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Crit Care Med 2017; 45:486.
  2. Hollenberg SM. Vasoactive drugs in circulatory shock. Am J Respir Crit Care Med 2011; 183:847.
  3. Lexicomp Online. Copyright © 1978-2023 Lexicomp, Inc. All Rights Reserved.
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