From the Guidelines
Norepinephrine is the recommended vasopressor for treating hypotension in patients with pulmonary embolism (PE), as it increases right ventricular inotropy and systemic blood pressure, promotes positive ventricular interactions, and restores coronary perfusion gradient. According to the 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism 1, norepinephrine is the preferred vasopressor, with a recommended dose of 0.2-1.0 mg/kg/min. This is because norepinephrine has been shown to improve hemodynamics in patients with PE, particularly those with right ventricular failure.
Some key points to consider when using norepinephrine in this setting include:
- Monitoring for excessive vasoconstriction, which may worsen tissue perfusion 1
- Using cautious volume loading, as volume overload can worsen right ventricular distension and decrease cardiac output 1
- Considering the use of dobutamine, which may be added to norepinephrine to increase cardiac output and improve tissue perfusion, although it may aggravate arterial hypotension if used alone 1
It's also important to note that other vasopressors, such as vasopressin and epinephrine, may be considered in certain situations, but norepinephrine is generally the first-line choice. The Surviving Sepsis Campaign guidelines also recommend norepinephrine as the first-choice vasopressor for septic shock 1, although the context of PE may require slightly different considerations. Overall, the use of norepinephrine in PE should be guided by the principles of minimizing morbidity, mortality, and improving quality of life, and should be tailored to the individual patient's needs and response to treatment.
From the FDA Drug Label
DOSAGE & ADMINISTRATION Norepinephrine Bitartrate Injection is a concentrated, potent drug which must be diluted in dextrose containing solutions prior to infusion. Restoration of Blood Pressure in Acute Hypotensive States Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, LEVOPHED can be administered before and concurrently with blood volume replacement
The vasopressor used to treat hypotension is norepinephrine (IV), also known as LEVOPHED.
- Key points:
- It should be diluted in dextrose containing solutions prior to infusion.
- Blood volume depletion should be corrected before administration.
- It can be administered in emergency situations to maintain intraaortic pressures. 2
From the Research
Vasopressor Treatment for Hypotension in Pulmonary Embolism
- Norepinephrine is a reasonable first choice for hemodynamic support in patients with acute pulmonary embolism (PE) and hypotension 3, 4.
- Other pressor agents such as isoproterenol hydrochloride and epinephrine may also be used 3.
- Arginine vasopressin may be considered as an adjunct to norepinephrine in certain cases, although its use is more commonly associated with septic shock 5, 6.
- The choice of vasopressor should be guided by the patient's individual clinical characteristics and the presence of any contraindications or concerns, such as pulmonary hypertension 5.
Key Considerations
- Patients with high-risk acute PE, defined by systemic hypotension, require intensive care and careful management of their hemodynamic status 4.
- The use of IV fluids and diuretics should be tailored to the individual patient's needs, with caution exercised in patients with evidence of right ventricular dysfunction or volume overload 4.
- Supplemental oxygen administration and avoidance of positive pressure ventilation may also be important considerations in the management of patients with acute PE 4.