What medications can be used to raise blood pressure in cases of hypotension?

Medications to Raise Blood Pressure in Hypotension

Norepinephrine is the first-choice vasopressor for treating hypotension, especially in septic shock, due to its reliable blood pressure elevating effects and moderate quality evidence supporting its use. 1

First-Line Medications for Hypotension

Vasopressors

• Norepinephrine: First-choice vasopressor for hypotension, particularly in septic shock. Typical infusion rate is 0.2-1.0 μg/kg/min 1
• Epinephrine: Can be added to or substituted for norepinephrine when additional blood pressure support is needed. Dosing range is 0.05-0.5 μg/kg/min 1, 2
• Dopamine: Should be used only in highly selected patients with low risk of tachyarrhythmias or those with relative bradycardia. Dosing at >5 μg/kg/min provides vasopressor effects 1
• Vasopressin: Can be added to norepinephrine (up to 0.03 U/min) to either raise mean arterial pressure or decrease norepinephrine dosage requirements 1

Context-Specific Considerations

• In cardiogenic shock with hypotension, inotropes may be needed alongside vasopressors 1
• In hypovolemic shock, fluid resuscitation should precede vasopressor therapy 1
• In vasodilatory shock that is refractory to first-line agents, angiotensin II may be considered 3

Second-Line Medications

Inotropes (for hypotension with cardiac dysfunction)

• Dobutamine: Used at 2-20 μg/kg/min when there is evidence of persistent hypoperfusion despite adequate fluid loading and vasopressor use 1
• Milrinone: Phosphodiesterase inhibitor used at 0.375-0.75 μg/kg/min, particularly useful when beta-blockade is contributing to hypotension 1
• Levosimendan: Can be used at 0.1 μg/kg/min (range 0.05-0.2 μg/kg/min) for patients with cardiogenic shock 1

Oral Agents (for chronic orthostatic hypotension)

• Midodrine: Alpha-1 agonist that can raise standing systolic blood pressure by 15-30 mmHg, with effects lasting 2-3 hours 4, 5

Special Situations

Refractory Shock

• When standard vasopressors fail, consider adding:
  • Higher doses of vasopressin (though doses >0.03-0.04 units/minute should be reserved for salvage therapy) 1
  • Angiotensin II for profound hypotension 3, 6
  • Corticosteroids (hydrocortisone) for potential relative adrenal insufficiency 1, 3

Pediatric Considerations

• In pediatric patients with fluid-refractory shock, dopamine is often the first-line vasopressor 1
• For catecholamine-resistant shock in children:
  • With low cardiac index and normal blood pressure: consider nitroprusside or nitroglycerin 1
  • With low cardiac index and low blood pressure: consider norepinephrine plus dobutamine or enoximone 1
  • With high cardiac index and low systemic vascular resistance: consider vasopressin, angiotensin, or terlipressin 1

Monitoring and Precautions

• Close monitoring of ECG and blood pressure is essential when using inotropes and vasopressors due to risks of arrhythmias, myocardial ischemia, and in the case of phosphodiesterase inhibitors, hypotension 1
• Arterial catheterization should be considered for all patients requiring vasopressors 1
• Vasopressors should be administered into a large vein to avoid extravasation and tissue necrosis 2
• Push-dose vasopressors (bolus administration) may be considered as a bridge to continuous infusion in acute situations, but have been associated with increased mortality in some observational studies 7, 8

Potential Adverse Effects

• Excessive vasoconstriction leading to organ ischemia 6
• Tachycardia and tachyarrhythmias 1, 2
• Hyperglycemia and hyperlactatemia 6
• Pulmonary edema, which may be fatal with epinephrine 2
• Renal impairment 2

Remember that the choice of vasopressor should be guided by the underlying cause of hypotension, patient comorbidities, and hemodynamic goals. Continuous monitoring and titration of therapy are essential for optimal outcomes.