Management of Hypotension in Patients on Maximum Doses of Epinephrine and Norepinephrine
For patients with persistent hypotension despite maximum doses of epinephrine and norepinephrine, the next step should be adding vasopressin (up to 0.03 U/min) to the treatment regimen. 1
Stepwise Approach to Refractory Hypotension
1. Add Vasopressin
- Add vasopressin as a bolus 1-2 IU followed by an infusion at 0.03 U/min 1
- Vasopressin works through a different mechanism than catecholamines, making it effective when patients have developed tachyphylaxis to epinephrine and norepinephrine 2
- This is particularly important in patients who have experienced maximal vasoconstriction as their internal compensatory response to shock 1
2. Consider Additional Fluid Resuscitation
- Ensure adequate volume status with crystalloid boluses (up to 20-30 ml/kg) 1
- Use balanced crystalloids or normal saline based on patient needs 1
- Consider albumin in addition to crystalloids when patients require substantial amounts of fluid 1
3. Add Glucagon for Beta-Blocker Users
- For patients on beta-blockers, add IV glucagon 1-2 mg 1, 2
- Glucagon works through a non-adrenergic pathway to increase cardiac output and may overcome beta-blockade 2
4. Consider Corticosteroids
- Methylprednisolone (40 mg) followed by stress-dose hydrocortisone (300 mg daily) may improve outcomes in refractory shock 3
- Corticosteroids can potentiate the effects of vasopressors and address relative adrenal insufficiency 3
5. Escalate Epinephrine Dosing
- If inadequate response after 10 minutes, consider doubling the bolus dose of epinephrine 1
- Consider starting an epinephrine infusion (0.05-0.1 μg/kg/min) if more than three epinephrine boluses have been administered 1
Special Considerations
For Anaphylactic Shock
- In Grade IV reactions (cardiac or respiratory arrest), follow advanced life support guidelines including IV epinephrine 1 mg 1
- Consider push-dose vasopressin (1 unit IV) as a bridge to continuous infusion in rapidly deteriorating patients 4
For Septic Shock
- Norepinephrine remains first-line, but adding vasopressin can help decrease norepinephrine dosage and potentially improve outcomes 1, 5
- Push-dose epinephrine (10-20 μg every 2 minutes) can temporarily resolve hypotension while preparing continuous infusions 6
For Cardiogenic Shock
- Consider adding dobutamine if there is evidence of persistent hypoperfusion despite adequate fluid loading and vasopressor use 1
- Monitor for tachyarrhythmias, which are more common with high-dose catecholamines 7
Extreme Measures for Refractory Cases
- Consider extracorporeal life support where available for patients with persistent shock despite all interventions 1
- Angiotensin II may be useful for rapid resuscitation of profoundly hypotensive patients 5
Monitoring and Safety
- Ensure continuous cardiac monitoring and frequent blood pressure measurements 2
- Watch for signs of excessive vasoconstriction causing organ ischemia/infarction 5
- Monitor for hyperglycemia, hyperlactatemia, and tachyarrhythmias 2, 5
By following this algorithmic approach, you can systematically address refractory hypotension in patients already on maximum doses of epinephrine and norepinephrine, improving their chances of survival and reducing morbidity.