Vasopressor use is an everyday exercise in critical care. Unfortunately, high-level evidence regarding these agents is often lacking. Furthermore, patients may react in unique ways. This chapter attempts to clarify some vasopressor basics, but beware – all of your patients will not read the book.
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The IBCC chapter is located here.
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Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
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Milirinone is listed in the chapter as a adenylyl cyclase inhibtor. This would decrease cAMP. I think it is a phosphodiesterase inhibitor, which would decreases cAMP breakdown.
is isoproterenol the same as isoprenaline? if so you’ll be happy to hear its used regularly in Australia, i don”t know how much it costs but there is usually plenty of it available
Any new thoughts on angiotensin II since your last post on it? When I use heroic doses of norepi, epi, and phenyl plus vaso, I wonder if it would benefit Would good equipoise gives it a niche in some scenarios? I haven’t had access yet since it’s either not on formulary or very restricted by pharmacy.
Do you use metaraminol? Often seems to be peripheral agent of choice in major trauma in London.
Vasopressin is apparently sometimes administered subcutaneously for diabetes insipidus, so I’d assume that it can’t be that dangerous to administer peripherally? If you can just jam 10 units SQ (or IM), I don’t see how extravasation can cause any significant harm.
https://www.ncbi.nlm.nih.gov/pubmed?term=28377801 (see fig 2)
https://www.drugs.com/pro/vasopressin.html#s-34068-7
I’d check your dosing for the epinephrine infusion in the text. I think you mean 5-10 mcg/min, not 5-10 mcg/kg/min.
It’s very well organized topic
Thanks for another great article!
Can you clarify what is low-dose epi for mostly inotropic action (vs vasopressor effect)? Is it 0 – 5 mcg/min or 0 – 5 mcg/kg/min?
In the article on cardiogenic shock, you state, “ At low doses (e.g., 0-5 mcg/min) epinephrine acts predominantly as an inotrope. “
But in this article you state, ” At low doses (below 5-10 mcg/kg/min), the predominant effect is as an inotrope, so it can be used for patients with low-output cardiogenic shock.”
0.01-0.05mcg/kg/min is our “inotropic” dose for Epi if we are using it. We try to use norepi + dobutamine for our cardiogenic shock patients (when it isn’t bradycardia driven) as epi has been linked with increased 30 day mortality.