Cardiovascular Medicine Book

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Vasopressor

Aka: Vasopressor, Vasoconstrictor, Push Dose Pressor, Vasopressor Extravasation
  1. See Also
    1. Hypotension
    2. Septic Shock
  2. Background
    1. See specific medications (follow links) for preparation and dosing protocols
    2. Vasopressors are typically used via Central Line access
      1. However may be used peripherally for stabilization in first 1-2 hours (see precautions below)
      2. Push Dose Pressors are typically used via Peripheral IV Access (see below)
  3. Precautions: General
    1. Vasopressors are second-line therapy for Hypotension after cause-specific measures
      1. Start with at least 30 ml/kg of crystalloid in Septic Shock
      2. Replace acute blood loss with blood
    2. Frequently reevaluate volume status, perfusion markers (e.g. Lactic Acid) and Hypotension response
      1. See Hypotension
      2. See Rapid Ultrasound in Shock
  4. Precautions: Peripheral Vasopressor administration
    1. Do not use Vasopressors via unreliable, small or deep peripheral site
      1. Use only larger bore, reliable superficial IVs that can be closely monitored
      2. Avoid peripheral hand IV or Ultrasound-guided deep brachial (occult extravasation risk)
    2. Best to transition within first 2 hours to Central Line Vasopressor delivery
    3. Monitor peripheral IV closely for extravasation
    4. Peripheral Vasopressor delivery appears safe for short-term use (studies looked at 12-24 hours)
      1. Recent studies have demonstrated Norepinephrine peripheral safety
      2. Push Dose Pressors (see below) also appear safe
      3. Ricard (2013) Crit Care Med 4(9): 2108-15 +PMID:23782969 [PubMed]
      4. Cardenas-Garcia (2015) J Hosp Med 10(9): 581-5 +PMID:26014852 [PubMed]
    5. Peripheral Vasopressor Extravasation management
      1. Direct others to obtain reliable access (other peripheral IV, IO Line, Central Line)
      2. Leave infiltrating catheter in place until following measures are completed
      3. Use the infiltrating catheter to withdraw as much infused Vasopressor from the site
      4. Phentolamine Mesylate SQ Immediately (even if skin site has not yet whitened)
        1. Dilute Phentolamine vial (5 mg/ml) in 9 ml Normal Saline
        2. Inject diluted phentolamine 0.1 to 0.2 mg/kg (up to 10 mg) SQ into extravasation site
        3. Second dose may be needed
      5. Consult plastic surgery
    6. References
      1. Orman and Weingart (2016) EM:Rap 16(5): 12-3
  5. Preparations: Push Dose Pressors
    1. Bolus pressors typically via peripheral IV
    2. General
      1. Used initially prior to central Intravenous Access
      2. Medications are used in diluted form
      3. Both Epinephrine and Phenylephrine have onset of action within 1 minute
      4. Phenylephrine duration of action at 10-20 minutes exceeds the 5-10 minute duration seen with Epinephrine
    3. Epinephrine (diluted to 10 mcg/ml)
      1. Epineprhine 10 mcg/ml 0.5 to 2 ml (5-20 mcg) every 2-5 minutes
      2. See Epinephrine for dilution approach (do not use undiluted cardiac Epinephrine)
    4. Intravenous Phenylephrine
      1. Phenylephrine (diluted to 10 mcg/ml) 0.5 to 2 ml (50-200 mcg) every 2-5 minutes
      2. See Phenylephrine for dilution approach (do not use undiluted Phenylephrine)
  6. Preparations: Pressor Infusions - Alpha adrenergic agents (primarily)
    1. Norepinephrine
      1. Indications
        1. Preferred first-line Vasopressor in adults
      2. Receptor Activity
        1. Alpha-1 agonist
        2. Lower beta adrenergic activity
      3. Dosing
        1. Infusion: 2 to 30 mcg/min
      4. Effects
        1. Strong Vasoconstrictor
        2. Minimal chronotropic activity
      5. Adverse effects
        1. Reflex Bradycardia
        2. Tachyarrhythmia
        3. May precipitate Myocardial Ischemia or infarction
    2. Epinephrine
      1. Receptor Activity
        1. Alpha-1 agonist
        2. Lower beta adrenergic activity
      2. Dosing
        1. Infusion: 1-10 mcg/min
        2. Push dose (see above): 5-20 mcg every 2-5 min
      3. Effects
        1. Strong inotropy
        2. Strong chronotropy
      4. Adverse effects
        1. May precipitate Myocardial Ischemia or infarction
    3. Dopamine
      1. Indications
        1. Preferred first-line Vasopressor in children
        2. Largely replaced by Norepinephrine in adults in U.S.
      2. Receptor Activity
        1. Alpha-1 agonist
        2. Moderate beta adrenergic activity
        3. Low Dopaminergic activity
      3. Dosing
        1. Infusion: 2 to 20 mcg/min
      4. Effects
        1. Precursor to Norepinephrine
        2. Inotropy and chronotropy at moderate doses
        3. Strong Vasoconstrictor at higher doses
    4. Phenylephrine
      1. Indications
        1. Primarily used as a push-dose pressor (see above), especially by anesthesia
      2. Receptor Activity
        1. Exclusively alpha-1 agonist
      3. Dosing
        1. Infusion: 40-200 mcg/min
        2. Push Dose Pressor: 50-200 mcg every 2-5 min prn
      4. Effects
        1. Strong Vasoconstrictor
        2. Minimal chronotropic activity
      5. Adverse effects
        1. Reflex Bradycardia
  7. Preparations: Pressor Infusions - Beta adrenergic agents (primarily)
    1. Dobutamine
      1. Receptor Activity
        1. Primarily Beta-1 Agonist
        2. Also activity as a Beta-2 Agonist
      2. Dosing
        1. Infusion: 5-40 mcg/kg/min
      3. Effects
        1. Strong inotropy
        2. Moderate chronotropy
        3. Mild Vasodilation
      4. Adverse effects
        1. Increases myocardial oxygen demand
        2. Arrhythmogenic
    2. Isoproteronol
      1. Indications
        1. Preferred first-line Vasopressor in adults
      2. Receptor Activity
        1. Beta-1 Agonist
        2. Beta-2 Agonist
      3. Dosing
        1. Infusion: 2 to 10 mcg/min
      4. Effects
        1. Strong inotropy
        2. Strong chronotropy
        3. No significant vascular effect (although may decrease systemic vascular resistance)
        4. Cardiac Output not appreciably affected
  8. Preparations: Pressor Infusions - Other sites of activity
    1. Vasopressin
      1. Indications
        1. Adjunct to other Vasopressors (e.g. Norepinephrine) in refractory Hypotension (especially Septic Shock)
      2. Receptor Activity
        1. Exclusively at vasopressin receptors (some on vasculature)
      3. Dosing
        1. Infusion: 0.01 to 0.04 units/min
      4. Effects
        1. Increases systemic vascular resistance while still maintaining CNS and cardiac blood flow
        2. Effective, even in severe acidosis
  9. Resources
    1. EM-Crit Blog (Scott Weingart)
      1. http://emcrit.org/wp-content/uploads/push-dose-pressors.pdf
  10. References
    1. Goldberg (2015) Crit Dec Emerg Med 29(3): 9-19

Vasoconstrictor Agents (C0042397)

Definition (MSH) Drugs used to cause constriction of the blood vessels.
Concepts Pharmacologic Substance (T121)
MSH D014662
SnomedCT 372881000, 8571001
English Agents, Vasoconstrictor, Agents, Vasopressor, Agonists, Vasoactive, Vasoactive Agonists, Vasoconstrictor Agents, Vasopressor Agents, vasoconstrictor, Drugs, Vasoconstrictor, Vasoconstrictor Drugs, Vasoconstrictors, Vasoconstrictor Drug, vasopressors, vasopressors (medication), vasoconstrictor agents, vasopressor agents, vasoconstrictors, vasopressor, Vasoconstrictor, Vasoconstrictor (product), Vasoconstrictor (substance), Vasoconstrictor, NOS, Vasopressor Drugs
French Agents vasoconstricteurs, Médicaments vasoconstricteurs, Vasoconstricteurs
Swedish Kärlsammandragande medel
Finnish Vasokonstriktorit
Russian VAZOAKTIVNYE AGONISTY, VAZOPRESSORNYE SREDSTVA, SOSUDOSUZHIVAIUSHCHIE SREDSTVA, SREDSTVA SOSUDOSUZHIVAIUSHCHIE, ВАЗОАКТИВНЫЕ АГОНИСТЫ, ВАЗОПРЕССОРНЫЕ СРЕДСТВА, СОСУДОСУЖИВАЮЩИЕ СРЕДСТВА, СРЕДСТВА СОСУДОСУЖИВАЮЩИЕ
Japanese 血圧上昇剤, 昇圧剤, 脈管作動物質(昇圧), 昇圧物質, 昇圧薬, 血管作動薬(昇圧), 血管収縮剤, 血管収縮薬, 血管収縮因子
Italian Farmaci vasocostrittori, Vasocostrittori
Croatian VAZOKONSTRIKTORI
Polish Środki podwyższające ciśnienie, Środki zwężające naczynia krwionośne, Leki kurczące naczynia
Czech vazokonstriktivní látky, vazokonstriktiva, vasokonstriktiva, vazoaktivní látky, vazokonstriktory, vazopresory
Spanish vasoconstrictor (producto), vasoconstrictor (sustancia), vasoconstrictor, Agonistas Vasoactivos, Vasoconstrictores, Vasopresores
German Vasoaktive Agonisten, Vasokonstriktorische Mittel, Vasopressorische Mittel
Portuguese Agentes Vasopressores, Agonistas Vasoativos, Vasoconstritores
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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