Vasopressors and Inotropic Agents

UCI Internal Medicine Residency Mini-Lecture Series

Objectives

Understand the vasopressor and inotropic

agent receptor physiology
Understand appropriate clinical application of
vasopressors and inotropic agents

Background

Vasopressors are class of drugs that elevate Mean

Arterial Pressure (MAP) by inducing
vasoconstriction.

Inotropes increase cardiac contractility.

Many drugs have both vasopressor and inotropic

effects.

Vasopressors are indicated for a decrease of >30

mmHg from baseline systolic blood pressure or MAP
<60 mmHg, when either condition results in endorgan dysfunction secondary to hypoperfusion.

Receptor Physiology

Main categories of adrenergic receptors

relevant to vasopressor activity:
Alpha-1adrenergic receptor
Beta-1, Beta-2 adrenergic receptors
Dopamine receptors

Receptor
Physiology
Receptor
Alpha-1
Adrenergic

Beta Adrenergic

Dopamine

Location Effect
Vascular

wall
Vasoconstriction
Increase duration of

Heart
contraction without
increased

chronotropy
Inotropy and
Beta-1 Heart
chronotropy
Blood
Beta-2 vessels
Vasodilation

Renal
Vasodilation
Splanchnic
(mesenteri

c)

Coronary

Cerebral

Vasoactive Medication Receptor Activity and

Clinical Effects
Drug
(Neosynephrine
) Phenylephrine
(Levophed)
Norepinephrine
(Adrenalin)
Epinephrine

(Intropin)
Dopamine
(mcg/kg/min)
0.5 to 2
5 to 10
10 to 20

Dobutamine
Isoproterenol

Predominant Clinical
AlphaDopaminer
Effects
1
Beta-1 Beta-2
gic
***

SVR , CO /

***

**

***

***

**

SVR , CO /
CO , SVR (low dose)
SVR/ (higher dose)

0
*
**

*
**
**

0
0
0

**
**
**

CO
CO , SVR
SVR

0/*

***

**

CO , SVR

***

***

CO , SVR

*** Very Strong Effect, ** Moderate effect, * Weak effect, 0 No effect.

Clinical
Application

1st Line Agent

Norepinephrine
(Levophed)
Phenylephrine
(Neosynephrine)
Dopamine
Dobutamine
Norepinephrine
(Levophed)
Dobutamine

Septic Shock

Heart Failure

Cardiogenic
Shock

Anaphylactic
Shock
Neurogenic
Shock

Hypotension

Epinephrine (Adrenalin)
Phenylephrine
(Neosynephrine)

Anesthe
Phenylephrine
siainduced (Neosynephrine)
Followin

2nd Line
Agent

Vasopressin
Epinephrine
(Adrenalin)
Milrinone

Vasopressin

Clinical Scenario I

72 year-old woman with DM type II, hypertension and

Stage II CKD is transferred from a Skilled Nursing
Facility for altered mental status. Her vitals upon arrival
are as follows: Temp 101F, BP 70/45, Hr 140, RR 20, O2
Sat 95% RA. Pertinent lab findings: WBC 21, Cr 3.5,
Lactic Acid 3.4, Positive UA.
After adequate IVF resuscitation, pt continues to remain
hypotensive BP 60-70s/30-40s and tachycardic Hr 130s.
What is the most appropriate 1st line
vasopressor/inotropic agent?
A.
B.
C.
D.

Epinephrine (Adrenalin)
Dobutamine
Norepinephrine (Levophed)
Dopamine

Clinical Scenario II

64 year-old man with PMH significant for CAD s/p MI and

PCI (2004; drug-eluting stents), ischemic cardiomyopathy
(EF 20-25%) with AICD (2007), who presents to ED with 1
week history of progressively worsening shortness of
breath, orthopnea and bilateral lower extremity edema,
after running out of all medications about 10 days ago.
In ED, vitals: Temp 99F, BP 75/48, Hr 75, RR 25, O2 Sat
91% on RA. CXR reveals vascular congestion and
bilateral pleural effusion. Bedside ultrasound reveals
significantly diminished EF.
What is the most appropriate 1st line
vasopressor/inotropic agent?
A.
B.
C.
D.

Epinephrine (Adrenalin)
Dobutamine
Norepinephrine (Levophed)
Dopamine

Clinical Scenario III

56 year-old obese man with PMH significant for

COPD and OSA, who was initially admitted to the
medicine floor for acute COPD exacerbation
secondary to community-acquired pneumonia,
was found to be in acute respiratory failure.
Versed and Succinylcholine were given for
emergent intubation. Vitals after intubation are as
follows: Temp 99.8F, BP 74/48, Hr 74. What is the
most appropriate 1st line vasopressor/inotropic agent?
A. Phenylephrine (Neosynephrine)
B. Dobutamine
C. Norepinephrine (Levophed)
D. Dopamine

Objective Summary

Understand the vasopressor and inotropic agent

receptor physiology

Alpha-1, Beta-1, and Beta-2 adrenergic receptors

induce vasoconstriction, inotropy plus chronotropy,
and vasodilation, respectively.
Dopamine receptors induce vasodilation (one subtype
induces norepinephrine release and vasoconstriction).

Objective Summary

Understand appropriate clinical application of

vasopressors and inotropic agents.

In hyperdynamic septic shock, norepinephrine or

phenylephrine is first-line agent. Vasopressin as secondline agent to reduce need for other pressors.
In cardiogenic shock, norepinephrine is preferred initial
agent. After establishing adequate perfusion,
Dobutamine added.
In anaphylactic shock, 1st line agent is Epinephrine
followed by Vasopressin as second line agent.
Epinephrine is the 1st line agent in hypotension after
CABG.
In both neurogenic shock and anesthesia-induced
hypotension, Neosynephrine is the 1 st line agent.