Vasopressors

Vasopressor & Inotrope Selection

Select the dominant shock physiology to see the preferred vasoactive strategy.

Shock physiology

Choose the physiology driving the current hemodynamic problem.

Quick framework

SVR
Low vascular tone Favor vasoconstriction with norepinephrine or vasopressin.
CO
Low cardiac output Add inotropy when blood pressure can tolerate it.
RV
RV failure Preserve systemic pressure while avoiding unnecessary increases in PVR.
LVOT
Dynamic LVOTO Increase preload and afterload. Avoid inotropy.

Vasopressor & Inotrope Map

Select a clinical scenario to compare agents, or select a drug to see where it fits.
Clinical scenario
Distributive
Cardiogenic
RV / Obstructive
LVOTO / Valvular
Rhythm
Special Situations
Showing:
Key physiology
Preferred
Consider
Avoid / caution
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Agents
Drug
Mechanism
Typical dose
Clinical pearls
Norepinephrine
Vasopressor
Mechanism α1 >>> β1
Typical dose 1–40 mcg/min
Clinical pearls First-line septic/distributive shock. Strong vasoconstriction with less tachyarrhythmia. Good MAP support. Relatively neutral PVR.
Vasopressin
Non-catecholamine vasopressor
Mechanism V1 / V2 agonist
Typical dose 0.03 U/min fixed
Clinical pearls Septic shock adjunct. Effective in acidemia. Relatively neutral PVR and useful in RV failure/PE. High doses risk digital and mesenteric ischemia.
Epinephrine
Vasopressor + inotrope
Mechanism β1 / β2 low dose, α1 higher dose
Typical dose 1–20 mcg/min
Clinical pearls Anaphylaxis, refractory shock, peri-arrest. Increases HR and CO. Raises lactate and glucose.
Phenylephrine
Pure vasoconstrictor
Mechanism Pure α1
Typical dose 40–180 mcg/min
Clinical pearls Raises SVR without β stimulation. Useful in AF with RVR and HOCM. Reflex bradycardia may lower CO. Avoid in RV failure.
Dobutamine
Inodilator
Mechanism β1 > β2
Typical dose 2.5–5 mcg/kg/min
Clinical pearls Improves CO in cardiogenic shock and RV failure. Can worsen hypotension and tachyarrhythmias.
Milrinone
Inodilator
Mechanism PDE-3 inhibitor
Typical dose 0.125–0.75 mcg/kg/min
Clinical pearls Inotropy + vasodilation independent of β receptors. Useful in RV failure, pulmonary HTN, and β-blocker patients. Long half-life, renal clearance, hypotension risk.
Dopamine
Catecholamine
Mechanism DA → β1 → α1 dose dependent
Typical dose 2–20 mcg/kg/min
Clinical pearls Arrhythmogenic. Inferior outcomes compared with norepinephrine. Rarely used.
Isoproterenol
Chronotrope / inotrope
Mechanism Pure β agonist
Typical dose 1–10 mcg/min
Clinical pearls Severe bradycardia and torsades. Potent chronotrope and inotrope. Can cause marked tachyarrhythmia and hypotension.
Clinical use
Cardiology Pearls
  • Massive PE: RV failure is the primary issue. Norepinephrine is usually first-line. Vasopressin is attractive because it is relatively PVR-neutral. Avoid phenylephrine.
  • HOCM / LVOTO: The physiology is the opposite of classic cardiogenic shock. Avoid inotropes and vasodilators. Increase preload and afterload.
  • RV failure: Hypoxia, hypercapnia, acidosis, high PEEP, and α-mediated pulmonary vasoconstriction can all worsen RV performance.
  • Wet and cold cardiogenic shock: Norepinephrine + dobutamine is a common combination when both MAP and forward flow need support.
  • Pure vasoconstriction without inotropy can worsen low-output cardiogenic shock.
  • Milrinone is particularly useful in RV failure, pulmonary HTN, and patients receiving chronic β-blockers.
  • Vasopressin may retain activity in profound acidemia when catecholamine responsiveness is reduced.

References

  1. Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., McIntyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., ... Levy, M. (2021). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2021. Intensive Care Medicine, 47(11), 1181–1247. https://doi.org/10.1007/s00134-021-06506-y
  2. De Backer, D., Biston, P., Devriendt, J., Madl, C., Chochrad, D., Aldecoa, C., Brasseur, A., Defrance, P., Gottignies, P., Vincent, J. L., & SOAP II Investigators. (2010). Comparison of dopamine and norepinephrine in the treatment of shock. New England Journal of Medicine, 362(9), 779–789. https://doi.org/10.1056/NEJMoa0907118
  3. Russell, J. A., Walley, K. R., Singer, J., Gordon, A. C., Hébert, P. C., Cooper, D. J., Holmes, C. L., Mehta, S., Granton, J. T., Storms, M. M., Cook, D. J., Presneill, J. J., Ayers, D., & VASST Investigators. (2008). Vasopressin versus norepinephrine infusion in patients with septic shock. New England Journal of Medicine, 358(9), 877–887. https://doi.org/10.1056/NEJMoa067373
  4. Levy, B., Clere-Jehl, R., Legras, A., Morichau-Beauchant, T., Leone, M., Frederique, G., Quenot, J. P., Kimmoun, A., Cariou, A., Lassus, J., Harjola, V. P., Meziani, F., Louis, G., Rossignol, P., Duarte, K., Girerd, N., Mebazaa, A., & Epinephrine Versus Norepinephrine for Cardiogenic Shock After Acute Myocardial Infarction Investigators. (2018). Epinephrine versus norepinephrine for cardiogenic shock after acute myocardial infarction. Journal of the American College of Cardiology, 72(2), 173–182. https://doi.org/10.1016/j.jacc.2018.04.051
  5. Mathew, R., Di Santo, P., Jung, R. G., Marbach, J. A., Hutson, J., Simard, T., Ramirez, F. D., Harnett, D. T., Merdad, A., Almufleh, A., Weng, W., Abdel-Razek, O., Fernando, S. M., Le May, M. R., Wells, G. A., Hibbert, B., & Russo, J. J. (2021). Milrinone as compared with dobutamine in the treatment of cardiogenic shock. New England Journal of Medicine, 385(6), 516–525. https://doi.org/10.1056/NEJMoa2026845
  6. Ventetuolo, C. E., & Klinger, J. R. (2014). Management of acute right ventricular failure in the intensive care unit. Annals of the American Thoracic Society, 11(5), 811–822. https://doi.org/10.1513/AnnalsATS.201312-446FR
  7. Naidu, S. S., Baran, D. A., Jentzer, J. C., Hollenberg, S. M., van Diepen, S., Basir, M. B., Grines, C. L., Diercks, D. B., Hall, S., Kapur, N. K., Kent, W., Sinha, S. S., Thiele, H., Zweck, E., & Henry, T. D. (2022). SCAI SHOCK stage classification expert consensus update: A review and incorporation of validation studies. Journal of the American College of Cardiology, 79(9), 933–946. https://doi.org/10.1016/j.jacc.2022.01.018