When should I start pressors for hypotension?

From the Guidelines

Start pressors for hypotension when fluid resuscitation fails to maintain adequate blood pressure (typically MAP <65 mmHg) despite initial fluid management, as recommended by the most recent guidelines 1.

Key Considerations

• The primary goal of pressor therapy is to maintain a mean arterial pressure (MAP) of at least 65 mmHg, as this has been shown to improve outcomes in patients with sepsis and septic shock 1.
• Norepinephrine is the preferred first-line vasopressor, due to its efficacy in reversing hypotension and its relatively favorable side effect profile compared to other agents 1.
• The decision to start pressors should be based on clinical judgment, taking into account factors such as the patient's overall hemodynamic status, lactate levels, and signs of organ perfusion 1.

Pressor Therapy

• Norepinephrine should be started at a dose of 0.05-0.1 mcg/kg/min and titrated up to 3.3 mcg/kg/min as needed to achieve the desired MAP 1.
• Vasopressin (0.03-0.04 units/min) can be added as a second agent if norepinephrine exceeds 0.5 mcg/kg/min, although its use should be guided by individual patient response and clinical context 1.
• Epinephrine (0.05-0.5 mcg/kg/min) can be used as an alternative second-line agent, although its use is generally reserved for patients who are refractory to other pressors or have specific indications such as cardiogenic shock 1.

Monitoring and Adjustments

• Blood pressure should be monitored continuously, and perfusion markers such as lactate, urine output, and mental status should be assessed regularly to guide adjustments in pressor therapy 1.
• The need for ongoing vasopressor support should be frequently reassessed, with the goal of weaning pressors as soon as possible to minimize potential adverse effects 1.

From the FDA Drug Label

Restoration of Blood Pressure in Acute Hypotensive States Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, LEVOPHED can be administered before and concurrently with blood volume replacement

You should start pressers for hypotension after correcting blood volume depletion as fully as possible. However, in emergency situations where intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, pressers like norepinephrine can be administered before and concurrently with blood volume replacement 2.

• Key consideration: Blood volume depletion should be corrected as much as possible before starting pressers.
• Emergency situations: Pressers can be started before full correction of blood volume depletion to maintain intraaortic pressures and prevent organ ischemia.

From the Research

Hypotension Treatment

When to start pressers for hypotension is a critical decision that depends on various factors, including the patient's condition, the underlying cause of hypotension, and the presence of other symptoms.

• The use of vasopressors, such as norepinephrine (NE), is a fundamental treatment for septic shock-induced hypotension, as it aims to correct vascular tone depression and improve organ perfusion pressure 3.
• Experts' recommendations currently position NE as the first-line vasopressor in septic shock, with vasopressin and its analogues as second-line options 3.
• The decision to start pressers for hypotension should be based on individual patient factors, such as history of chronic hypertension, central venous pressure (CVP), and diastolic arterial pressure (DAP) 3.

Push-Dose Vasopressors

Push-dose vasopressors, such as epinephrine and phenylephrine, are commonly used in emergency departments to transiently improve hypotension in patients with septic shock 4, 5.

• A study on push-dose epinephrine use in critical care transport found that it was effective in temporarily resolving hypotension, with close adherence to protocol and rare adverse events 5.
• Another study on push-dose vasopressin found that it improved hemodynamics in a patient with vasodilatory septic shock 4.

Hypotension Management

The management of hypotension in critically ill patients requires careful consideration of various factors, including the depth and duration of hypotension, as well as the patient's response to treatment 6.

• A study on the association between prehospital hypotension depth and dose with survival following out-of-hospital cardiac arrest found that severity and duration of hypotension were significantly associated with worse outcomes 6.
• Another study found that systolic pressure variation was a sensitive indicator of the response of cardiac output to volume infusion in patients with sepsis-induced hypotension 7.