From the Guidelines
Vasopressor therapy is primarily indicated for patients with persistent hypotension despite adequate fluid resuscitation, typically in shock states, with the goal of targeting a mean arterial pressure (MAP) of 65 mm Hg 1. The main indications for vasopressor therapy include:
- Septic shock
- Cardiogenic shock
- Hypovolemic shock (when fluid resuscitation alone is insufficient)
- Neurogenic shock
- Anaphylactic shock (after initial epinephrine and fluid resuscitation) Common vasopressors and their typical starting doses include:
- Norepinephrine: 0.1-0.5 mcg/kg/min
- Epinephrine: 0.01-0.1 mcg/kg/min
- Vasopressin: 0.01-0.04 units/min, which can be added to norepinephrine with the intent of either raising MAP or decreasing norepinephrine dosage 1
- Phenylephrine: 0.1-0.5 mcg/kg/min
- Dopamine: 2-20 mcg/kg/min, which can be used as an alternative vasopressor agent to norepinephrine only in highly selected patients 1 When initiating vasopressors, it is essential to start with a single agent and titrate to achieve a MAP goal, typically 65 mmHg or higher, while monitoring for side effects such as arrhythmias, tissue ischemia, and organ dysfunction. Vasopressors work by increasing systemic vascular resistance and cardiac output, thereby improving blood pressure and tissue perfusion, and should be used in conjunction with addressing the underlying cause of shock and optimizing fluid status 1. It is also crucial to note that low-dose vasopressin is not recommended as the single initial vasopressor for treatment of sepsis-induced hypotension, and vasopressin doses higher than 0.03–0.04 units/minute should be reserved for salvage therapy 1.
From the FDA Drug Label
Vasopressin injection is indicated to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines. Vasopressin injection is indicated to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines. (1)
The indications for vasopressor (vasopressin) therapy are:
- Vasodilatory shock: to increase blood pressure in adults who remain hypotensive despite fluids and catecholamines. Specific uses include:
- Post-cardiotomy shock
- Septic shock 2 2
From the Research
Indications for Vasopressor Therapy
The indications for vasopressor therapy include:
- Vasodilatory shock, which can be caused by septic shock, post-cardiovascular surgery, post-acute myocardial infarction, postsurgery, other causes of an intense systemic inflammatory response, and drug-associated anaphylaxis 3
- Distributive shock, characterized by inappropriate vasodilation 4
- Cardiogenic shock, although the evidence for vasopressors is limited in this condition 4
- Obstructive shock, where vasopressors can temporize a patient's blood pressure until definitive therapy can reverse the underlying cause 4
- Hypovolemic shock, although the preferred treatment is correction of the volume deficit, and the use of vasopressors is more controversial in this condition 4
Patient Selection
Patient selection for vasopressor therapy is crucial, and the choice of vasopressor and dose vary widely due to patient and physician practice heterogeneity 3, 5. Factors that affect the body's response to vasopressors include acidosis and adrenal insufficiency 4.
Vasopressor Agents
Commonly used vasopressor agents include:
- Norepinephrine, which is the first-choice vasopressor in septic and vasodilatory shock 3, 5
- Vasopressin, which can be added in patients not responsive to norepinephrine 3, 5
- Epinephrine, which can be added in patients not responsive to norepinephrine 3, 5
- Angiotensin II, which may be useful for rapid resuscitation of profoundly hypotensive patients 3, 5
- Dopamine, which is recommended only in bradycardic patients 5
Administration
Vasopressors can be administered through central venous access or peripherally, and the choice of administration route depends on the patient's condition and the physician's preference 4. Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states 4.