Comprehensive Table of Vasopressors and Inotropes
Below is a detailed reference table for vasopressors and inotropes used in critical care, synthesized from current evidence-based guidelines and clinical practice standards 1, 2, 3, 4, 5, 6, 7, 8.
VASOPRESSORS
| Agent | Dose Range | Administration | Receptor Action | Contraindications | Side Effects | Renal Safety | Hepatic Safety | Pregnancy | Lactation | Special Notes |
|---|---|---|---|---|---|---|---|---|---|---|
| Norepinephrine | 0.01-3 mcg/kg/min (typical: 0.05-0.5 mcg/kg/min) | IV continuous infusion via central line preferred | α1 (+++), α2 (++), β1 (++) | None absolute; use caution in mesenteric/peripheral vascular disease | Arrhythmias, tissue necrosis with extravasation, digital/limb ischemia, hyperglycemia, hyperlactatemia | Generally safe; may reduce renal blood flow at high doses but maintains MAP which preserves renal perfusion | Safe; no dose adjustment needed | Category C; use when benefit outweighs risk; preferred over dopamine in pregnancy | Likely excreted in breast milk; use caution | First-line vasopressor for most shock states [1,4,5]. Minimal effect on heart rate. Titrate to lowest effective dose. Risk of excessive vasoconstriction causing organ ischemia [4]. |
| Epinephrine | 0.01-0.5 mcg/kg/min | IV continuous infusion via central line | α1 (+++), β1 (+++), β2 (++) | None absolute; caution in coronary artery disease | Tachycardia, arrhythmias, myocardial ischemia, hyperglycemia, hyperlactatemia (more than NE), anxiety, tremor | May reduce splanchnic blood flow; maintain adequate MAP | Safe; no adjustment needed | Category C; acceptable in life-threatening situations | Excreted in breast milk; use caution | Second-line when norepinephrine inadequate [4,5]. Increases myocardial oxygen demand significantly. Causes more pronounced metabolic effects than norepinephrine. Can be used as inotrope at low doses. |
| Vasopressin | 0.01-0.04 units/min (fixed dose, typically 0.03-0.04 units/min) | IV continuous infusion via central or peripheral line | V1a (vasoconstriction), V2 (antidiuretic), V1b (ACTH release) | Caution in coronary artery disease without adequate coronary perfusion | Cardiac ischemia, mesenteric ischemia, hyponatremia, skin necrosis, digital ischemia, decreased cardiac output | May preserve renal perfusion via NO-mediated effects [1]; paradoxically renal-protective in some cases | Safe; no adjustment needed | Category C; limited data; use only if clearly needed | Unknown if excreted; use caution | Norepinephrine-sparing agent [1]. Do NOT titrate—use fixed dose. May cause cardiac depression. Useful in catecholamine-refractory shock. Paradoxically produces NO which may limit vasoconstriction [1]. |
| Phenylephrine | 0.5-3 mcg/kg/min (up to 5 mcg/kg/min) | IV continuous infusion via central line preferred | α1 (+++) pure | Severe hypertension, ventricular tachycardia | Reflex bradycardia, decreased cardiac output, hypertension, tissue necrosis with extravasation | Reduces renal blood flow; use cautiously | Safe; no adjustment needed | Category C; preferred vasopressor in obstetric anesthesia [9] | Likely safe; minimal data | Pure vasoconstrictor with NO inotropic effect [3]. Causes reflex bradycardia. May decrease cardiac output. Useful when tachycardia is problematic. Easy to titrate [9]. |
| Dopamine | 5-20 mcg/kg/min (dose-dependent effects) | IV continuous infusion via central line | Low dose (2-5): DA1, DA2; Medium (5-10): β1; High (>10): α1 | Pheochromocytoma, uncorrected tachyarrhythmias | High arrhythmia risk, tachycardia, increased myocardial oxygen demand, tissue necrosis | "Renal-dose" dopamine (2-5 mcg/kg/min) does NOT provide renal protection—this is a discredited concept | Safe; no adjustment needed | Category C; use only if necessary | Excreted in breast milk; contraindicated | Fallen to almost no-use recommendation due to adverse effects [4]. Higher mortality and arrhythmia risk vs norepinephrine. Avoid as first-line [1,3,4]. May use in bradycardic shock when pacing unavailable. |
| Angiotensin II | 2.5-40 ng/kg/min (start 20 ng/kg/min) | IV continuous infusion via central or peripheral line | AT1 (vasoconstriction), AT2 | Hypersensitivity | Thrombosis (higher risk), hypertension, delirium, fungal infection, hyperkalemia | Generally safe; may improve renal perfusion in some patients | Safe; no adjustment needed | Category C; avoid unless no alternatives | Unknown excretion; avoid | Norepinephrine-sparing agent [1]. Useful for rapid resuscitation of profoundly hypotensive patients [4]. May be beneficial in catecholamine-refractory shock. Increased thrombotic risk requires monitoring. |
INOTROPES
| Agent | Dose Range | Administration | Receptor Action | Contraindications | Side Effects | Renal Safety | Hepatic Safety | Pregnancy | Lactation | Special Notes |
|---|---|---|---|---|---|---|---|---|---|---|
| Dobutamine | 2.5-20 mcg/kg/min (typical: 2.5-10 mcg/kg/min) | IV continuous infusion via central or peripheral line | β1 (+++), β2 (++), α1 (+) | Idiopathic hypertrophic subaortic stenosis, severe hypotension without vasopressor support | Tachycardia, arrhythmias, hypotension (vasodilation), increased myocardial oxygen demand, ischemia | Safe; improves renal perfusion by increasing cardiac output | Safe; no adjustment needed | Category B; relatively safe but use only when needed | Unknown excretion; use caution | First-line inotrope when myocardial function is depressed [1,2]. Causes vasodilation (may worsen hypotension—combine with vasopressor). Doses 2.5-6 mcg/kg/min achieve goals in only 30-70% of patients; higher doses offer no benefit [10]. Similar outcomes to milrinone [2]. |
| Milrinone | Loading: 50 mcg/kg over 10 min (optional); Maintenance: 0.125-0.75 mcg/kg/min | IV continuous infusion via central or peripheral line | Phosphodiesterase-3 inhibitor (increases cAMP) | Severe aortic or pulmonary stenosis | Hypotension (vasodilation), arrhythmias, thrombocytopenia, headache | Renally eliminated; reduce dose by 50-70% in renal impairment (CrCl <50 mL/min) | Safe; no adjustment needed | Category C; limited data; use only if necessary | Unknown excretion; use caution | Mechanism independent of β-receptors—useful in patients on beta-blockers [2]. Causes vasodilation (combine with vasopressor). Long half-life (2-3 hours) makes titration difficult. Similar outcomes to dobutamine [2]. Avoid loading dose in hypotensive patients. |
| Epinephrine (as inotrope) | 0.01-0.1 mcg/kg/min | IV continuous infusion via central line | α1 (+++), β1 (+++), β2 (++) | See vasopressor section | See vasopressor section | See vasopressor section | See vasopressor section | See vasopressor section | See vasopressor section | At low doses (<0.1 mcg/kg/min), β-effects predominate providing inotropy. At higher doses, α-effects cause vasoconstriction. Increases oxygen transport more reliably than norepinephrine [10]. |
| Dopamine (as inotrope) | 5-10 mcg/kg/min | IV continuous infusion via central line | Medium dose: β1 primarily | See vasopressor section | See vasopressor section | See vasopressor section | See vasopressor section | See vasopressor section | See vasopressor section | At medium doses (5-10 mcg/kg/min), provides inotropic support. Avoid due to high arrhythmia risk [4]. Use only when other agents unavailable. |
| Levosimendan | Loading: 6-12 mcg/kg over 10 min (optional); Maintenance: 0.05-0.2 mcg/kg/min for 24 hours | IV continuous infusion via central or peripheral line | Calcium sensitizer + PDE-3 inhibitor | Severe hypotension, mechanical obstruction, severe renal/hepatic impairment | Hypotension, headache, arrhythmias, hypokalemia | Use caution in severe renal impairment | Contraindicated in severe hepatic impairment | Limited data; avoid unless necessary | Unknown excretion; avoid | Mechanism independent of β-receptors [2]. Long-acting active metabolites (half-life ~80 hours). Causes vasodilation. Not available in all countries (not FDA-approved in US). May be considered in beta-blocked patients. |
Key Clinical Principles
Norepinephrine is the first-line vasopressor for most shock states, including septic shock, with the lowest risk profile 1, 4, 5. When myocardial dysfunction is present, dobutamine remains the first-line inotrope 1, 2.
Critical Considerations:
All vasoactive drugs have a narrow therapeutic spectrum and expose patients to potentially lethal complications 1. Titrate to minimal efficacious dose and wean as promptly as possible.
Vasopressors increase myocardial oxygen demand, ischemic burden, and risk of malignant arrhythmias—use lowest doses for shortest duration 2.
Combination therapy: When norepinephrine alone is inadequate, add vasopressin (fixed dose 0.03-0.04 units/min) or angiotensin II as norepinephrine-sparing agents 1, 4. If tissue perfusion remains inadequate despite adequate MAP, add an inotrope like dobutamine 5.
Dopamine should be avoided as first-line therapy due to significantly higher arrhythmia risk and mortality compared to norepinephrine 1, 3, 4.
Milrinone and levosimendan are particularly useful in patients on chronic beta-blocker therapy since their mechanisms are independent of β-adrenergic receptors 2.
Phenylephrine is the preferred vasopressor in obstetric anesthesia for cesarean section under spinal anesthesia, as it maintains maternal blood pressure without causing fetal acidosis 9.
Extravasation precautions: Norepinephrine, epinephrine, dopamine, and phenylephrine cause severe tissue necrosis with extravasation—central line administration is strongly preferred for these agents.
Renal-dose dopamine is a myth—low-dose dopamine does NOT provide renal protection and this practice should be abandoned 3.
Pregnancy considerations: Most vasopressors and inotropes are Category C. Phenylephrine is preferred in obstetric anesthesia 9. Norepinephrine is preferred over dopamine when vasopressor support is needed in pregnancy.
Monitoring: Invasive hemodynamic monitoring with pulmonary artery catheter is increasingly advocated as standard of care in cardiogenic shock to guide tailored therapy 2.