Use of Inotropes and Vasopressors in Intracranial Hemorrhage with Hypotension
Yes, you can and should use vasopressors (and inotropes when indicated) in patients with intracranial hemorrhage and hypotension, but only after addressing reversible causes of hypotension, particularly hypovolemia from concurrent hemorrhagic shock. Persistent hypotension adversely affects neurological outcomes and must be corrected 1.
Critical First Step: Identify and Correct the Cause of Hypotension
- Never transport or manage an ICH patient who remains hypotensive until causes have been identified and corrected 1
- In trauma patients with ICH, concurrent hemorrhagic shock is common and must be addressed first 1
- Correction of major hemorrhage takes precedence - damage control surgery and blood product resuscitation should not be delayed in attempts to speed transfer 1
- Norepinephrine should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement can be completed 2
When Vasopressors/Inotropes Are Indicated
After excluding or treating hypovolemia, judicious use of vasopressors or inotropes is appropriate to maintain adequate cerebral perfusion pressure (CPP) 1:
- Use vasopressors when hypotension persists despite adequate resuscitation 1
- Consider vasopressors to offset hypotensive effects of sedative agents required for intubation and transport 1
- The goal is to maintain adequate mean arterial pressure (MAP) to ensure cerebral perfusion 1
Specific Agent Selection
Vasopressors (First-Line)
- Metaraminol infusion is specifically recommended in the guidelines for brain-injured patients 1
- Norepinephrine is indicated for blood pressure control in acute hypotensive states and as adjunct treatment in cardiac arrest and profound hypotension 2
- Ephedrine or metaraminol should be immediately available during induction to treat immediate hypotension 1
Inotropes (When Cardiac Dysfunction Present)
- Assess cardiac function before choosing between vasopressors and inotropes 1
- If myocardial dysfunction is present (from cardiac contusion, pericardial effusion, or secondary to brain injury with intracranial hypertension), use an inotropic agent such as dobutamine or epinephrine 1
- In the absence of cardiac output monitoring, suspect cardiac dysfunction if there is poor response to fluid expansion and norepinephrine 1
Blood Pressure Targets
- Maintain CPP of approximately 70 mm Hg to minimize reflex vasodilation or ischemia 1
- For previously hypertensive patients, raise blood pressure no higher than 40 mm Hg below the preexisting systolic pressure 2
- Target systolic blood pressure of 80-100 mm Hg is generally sufficient to maintain circulation to vital organs 2
- Be aware that blood pressure elevation to maintain CPP may advance intracranial hypertension in some patients 1
Critical Pitfalls to Avoid
- Do not use vasopressors as a substitute for volume resuscitation - this can cause severe peripheral and visceral vasoconstriction, decreased renal perfusion, tissue hypoxia, and lactate acidosis 2
- Avoid excessive fluid resuscitation that elevates central venous pressure (CVP), as this can worsen intracranial hypertension by reducing brain compliance 3
- Do not use norepinephrine in patients with mesenteric or peripheral vascular thrombosis unless necessary as a life-saving procedure 2
- Monitor for occult blood volume depletion if requiring high or escalating vasopressor doses 2
Monitoring Requirements
- Place arterial line with transducer at the level of the tragus for accurate pressure monitoring 1
- Consider ICP monitoring in patients with clinical evidence of increased ICP to guide CPP management 1
- Central venous pressure monitoring is helpful in detecting occult blood volume depletion 2
- Titrate vasopressor dosage according to individual patient response 2