When should adrenaline be used in a patient with cardiogenic shock?

Use of Adrenaline (Epinephrine) in Cardiogenic Shock

Epinephrine (adrenaline) should NOT be used as a first-line agent in cardiogenic shock and should be restricted to use as rescue therapy in cardiac arrest only. 1

First-Line Management Approach for Cardiogenic Shock

• Initial management should include fluid challenge (250 mL/10 min) if clinically indicated, followed by an inotropic agent if systolic blood pressure remains <90 mmHg 1
• Norepinephrine is recommended as the preferred vasopressor when the combination of an inotropic agent and fluid challenge fails to restore adequate blood pressure and organ perfusion 1, 2
• Dobutamine is the first-line inotropic agent for increasing cardiac output in cardiogenic shock 3, 4, 5

Appropriate Vasopressor Selection

• Norepinephrine should be administered through a central line when inotropic therapy fails to restore systolic blood pressure >90 mmHg with persistent signs of organ hypoperfusion 1
• Vasopressors should be used with caution in cardiogenic shock as it is usually associated with high systemic vascular resistance 1
• All vasopressors should be discontinued as soon as possible once hemodynamic stability is achieved 1

Why Epinephrine Should Be Avoided

• The European Society of Cardiology explicitly states that epinephrine is not recommended as an inotrope or vasopressor in cardiogenic shock 1
• Epinephrine is associated with an increased incidence of refractory shock and observational studies suggest an increased risk of death 5
• Epinephrine should be restricted to use as rescue therapy in cardiac arrest only 1

Alternative Agents for Refractory Cases

• Levosimendan may be considered as an alternative inotrope, especially in patients on beta-blocker therapy, as its inotropic effect is independent of beta-adrenergic stimulation 1, 3
• In patients with right ventricular failure and pulmonary hypertension, milrinone may be beneficial due to its pulmonary vasodilatory effects 2, 6
• For patients not responding to pharmacologic therapy, mechanical circulatory support should be considered rather than combining multiple inotropes 3

Monitoring Parameters

• Continuous monitoring of organ perfusion markers is essential, including urine output, lactate clearance, mental status, and mixed venous oxygen saturation 2, 3
• Invasive hemodynamic monitoring with an arterial line is recommended for all patients with cardiogenic shock 2, 3
• Treatment targets should include SBP >90 mmHg and cardiac index >2 L/min/m² 2

Important Caveats

• All inotropes should be used at the lowest possible doses for the shortest duration due to their propensity to increase myocardial oxygen demand and risk of arrhythmias 2
• Recent retrospective data suggests norepinephrine use in cardiogenic shock may be associated with increased 30-day mortality, highlighting the need for careful patient selection and monitoring 7
• Mechanical circulatory support should be considered early for potentially reversible causes of acute heart failure as a bridge to treatment response 1