Pressor selection — clinical pearls
1. Norepinephrine (Levophed) — 1st line in septic shock; 2nd line otherwise behind dopamine. β1 + α agonist.
• Start 1 mcg/min, max 30 mcg/min — OR — 0.01 mcg/kg/min, max 0.3 mcg/kg/min.
2. Dopamine — hypotension refractory to fluids (+ chronotropy).
• 1-5 mcg/kg/min: renal dose (often ineffective)
• 5-10 mcg/kg/min: β-primary
• 10-40 mcg/kg/min (max): α + β + dopaminergic
3. Dobutamine — cardiogenic hypotension, MI, CHF.
• 2-20 mcg/kg/min, physician-titrated to indirect cardiac output measures. DO NOT write nursing titration order.
4. Vasopressin — adjunct to NE in shock; 4 units/hr IV (0.01-0.04 units/min).
5. Hydrocortisone 50 mg q6h, taper over 11 days, may be added in refractory septic shock.
Consider colloid (Hespan / Hetastarch) 500 mL bolus when oncotic pressure is low — no survival benefit in sepsis.
↓ SVR → cold, clammy hands/feet. CO = HR × SV.
Source: fprmed.com — ER Pressors reference.
Receptor activity & effects
| Agent (dose) | α1 | β1 | β2 | DA | Hemodynamic effect | Indication |
|---|---|---|---|---|---|---|
| Norepinephrine (Levophed) 1-30 mcg/min | +++ | ++ | 0 | 0 | SVR ↑↑ / CO ↔↓↑ | Sepsis |
| Phenylephrine (Neo-Synephrine) 40-180 mcg/min | +++ | 0 | 0 | 0 | SVR ↑↑ / CO ↔↑ | Sepsis, neurogenic shock |
| Epinephrine | +++ | +++ | ++ | 0 | CO ↑↑ / SVR ↓ (low) / SVR ↔↑ (high) | Anaphylaxis, ACLS, sepsis |
| Dopamine — low (0.5-2 mcg/kg/min) | 0 | + | 0 | ++ | CO ↑ / SVR ↑↓ | Sepsis, cardiogenic shock |
| Dopamine — mid (5-10 mcg/kg/min) | + | ++ | 0 | ++ | CO ↑ | Cardiogenic shock |
| Dopamine — high (10-20 mcg/kg/min) | ++ | ++ | 0 | ++ | SVR ↑↑ | Refractory hypotension |
| Dobutamine 2.5-20 mcg/kg/min | 0/+ | +++ | ++ | 0 | CO ↑ / SVR ↓ | Cardiogenic shock |
| Isoproterenol 2-10 mcg/min | 0 | +++ | +++ | 0 | CO ↑ / SVR ↓ | Cardiogenic shock + bradycardia |
| Vasopressin 0.01-0.04 U/min | — | — | — | — | V2 vasoconstriction; augments catecholamines | Adjunct in shock |
Vasopressors / Inotropes
| Drug | Range | Notes |
|---|---|---|
| Epinephrine infusion | 0.05-1 mcg/kg/min | Cold shock, anaphylaxis |
| Norepinephrine | 0.05-1 mcg/kg/min | Warm/septic shock |
| Dopamine | 5-20 mcg/kg/min | Bridge to central |
| Dobutamine | 5-20 mcg/kg/min | Cardiogenic shock |
| Vasopressin | 0.0003-0.002 U/kg/min | Refractory septic shock |
| Milrinone | 0.25-0.75 mcg/kg/min | Inodilator, watch BP |
Push-dose pressors
Quick scenarios
Phenylephrine
Pure α-agonist — use when already tachycardic
Onset
1 minute
Duration
5–10 min (usually 5)
Preparation
- 1Start with phenylephrine 10 mg/mL (1 mL vial)
- 2Mix 1 mL phenylephrine + 100 mL NS bag
- 3Draw up into 10 cc syringe → final 100 mcg/mL
Titration
0.5–2 mL (50–200 mcg) IV q1–5 min, titrate to MAP ≥ 65
- • Causes reflex bradycardia — ideal for tachydysrhythmias with hypotension
- • Avoid in pure cardiogenic shock (↑ afterload, no inotropy)
Epinephrine
α + β agonist — inotropy + chronotropy + vasoconstriction
Onset
1 minute
Duration
5–10 min
Preparation
- 1Take 1 mL of 0.1 mg/mL epi (cardiac amp, 1:10,000)
- 2Mix into 9 mL NS in a 10 cc syringe
- 3Final concentration: 10 mcg/mL (1:100,000)
Titration
0.5–2 mL (5–20 mcg) IV q2–5 min, titrate to MAP ≥ 65
- • Drip alternative: 2–10 mcg/min IV infusion as bridge
- • Preferred when bradycardia, anaphylaxis, or peri-arrest hypotension
