What are the recommended IV (intravenous) medications to increase blood pressure in patients with hypotension?

Intravenous Medications for Increasing Blood Pressure

For patients with hypotension, norepinephrine is the first-line vasopressor for increasing blood pressure, with an initial dose of 0.02 mg/kg/min that can be titrated up to 0.1-0.2 mg/kg/min as needed. 1

First-Line IV Vasopressors

Norepinephrine

• Initial dose: 0.02 mg/kg/min IV
• Titration: Increase as needed to achieve target MAP ≥65 mmHg
• Maximum dose: 0.1-0.2 mg/kg/min
• Mechanism: Combined alpha and beta adrenergic effects
• Indications: First-line for most forms of shock, particularly septic shock 1, 2

Phenylephrine

• Initial dose: Alpha-1 adrenergic receptor agonist for clinically important hypotension 3
• Indications: Useful in situations where tachycardia should be avoided
• Caution: Pure alpha agonist without inotropic effects

Epinephrine

• Indication: FDA-approved for hypotension associated with septic shock 4
• Consideration: Can be used as second-line agent if norepinephrine is insufficient 1
• Caution: Higher doses carry risk of adverse events including tachycardia and arrhythmias 2

Second-Line Options

Vasopressin

• Dosing: 0.04 units/min
• Indication: Add when MAP remains inadequate despite norepinephrine
• Benefit: Non-catecholamine vasopressor that can reduce norepinephrine requirements 1, 5

Dopamine

• Caution: Generally fallen out of favor due to increased risk of arrhythmias 5
• Limited use: Consider only when other agents unavailable

Specialized Situations

Cardiogenic Shock

• Consider adding dobutamine if cardiac output remains inadequate despite adequate blood pressure 2
• Helps improve cardiac contractility without excessive vasoconstriction

Beta-Blocker Toxicity

• Consider glucagon (5-10 mg IV bolus followed by 1-5 mg/h infusion) 1
• High-dose epinephrine infusion may be effective 1

Calcium Channel Blocker Toxicity

• Consider calcium chloride: 20 mg/kg (0.2 mL/kg of 10% solution) IV over 5-10 minutes 1
• Follow with infusion of 20-50 mg/kg/hour if beneficial effect observed

Monitoring and Targets

• Target MAP ≥65 mmHg in most patients 1
• Consider invasive arterial blood pressure monitoring for patients requiring vasopressors 1
• Monitor for signs of excessive vasoconstriction (cool extremities, decreased urine output)
• Assess for arrhythmias, especially with catecholamine vasopressors

Important Considerations

• Fluid status: Ensure adequate volume resuscitation before/during vasopressor therapy
• Central access: Ideally administer vasopressors through central venous access to avoid extravasation
• Peripheral administration: If central access unavailable, norepinephrine can be started peripherally until central access is established 1
• Transition plan: Begin oral antihypertensives before discontinuing IV vasopressors to prevent rebound hypotension 6

Pitfalls to Avoid

• Excessive fluid administration before vasopressor initiation in certain populations (e.g., pregnant patients at risk for pulmonary edema) 1
• Delay in starting vasopressors when indicated (increases mortality)
• Rapid discontinuation without transition to oral agents
• Using high-dose epinephrine or dopamine as first-line agents due to increased adverse events 2

Vasopressor selection should be guided by the underlying cause of hypotension, patient comorbidities, and hemodynamic goals. Continuous reassessment of the patient's response to therapy is essential for optimal management.