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Chapter 47. Vasoactive Medications

Ruchir Gupta, MD

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    AMA Citation
    Gupta R. Gupta R Gupta, Ruchir.Chapter 47. Vasoactive Medications. In: Atchabahian A, Gupta R. Atchabahian A, Gupta R Eds. Arthur Atchabahian, and Ruchir Gupta.eds. The Anesthesia Guide New York, NY: McGraw-Hill; 2013. http://accessanesthesiology.mhmedical.com/content.aspx?bookid=572&sectionid=42543632. Accessed February 29, 2020.
    MLA Citation
    Gupta R. Gupta R Gupta, Ruchir.. "Chapter 47. Vasoactive Medications." The Anesthesia Guide Atchabahian A, Gupta R. Atchabahian A, Gupta R Eds. Arthur Atchabahian, and Ruchir Gupta. New York, NY: McGraw-Hill, 2013, http://accessanesthesiology.mhmedical.com/content.aspx?bookid=572&sectionid=42543632.

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See following table.

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Vasopressors and Inotropes
DrugsReceptors activatedHemodynamic effectsDilution (in 250 mL)Final concentrationIV infusion rate (μg/kg/min)IV bolus (if applicable)Special precautions/comments
Adrenergic agonists
Epinephrineα1, α2, β1, β2, β3
  • HR ↑
  • MAP ↑
  • CO ↑
  • PVR ↑–
4 mg16 μg/mL0.02–0.3 (2–20 μg/min)Variable, from 5 μg to 1 mg
Norepinephrine (Levophed®)α1, α2, β1
  • HR ↓
  • MAP ↑↑
  • CO –
  • PVR ↑↑
4 mg16 μg/mL0.05–0.5
Phenylephrine (Neosynephrine®)α1, weak α2, weak β1
  • HR ↓
  • MAP ↑↑
  • CO ↓
  • PVR ↑↑
10 or 20 mg40 or 80 μg/mL0.15–0.7540–80 μg
Ephedrineα1 (indirectly), β1, β2
  • HR ↑
  • MAP ↑
  • CO ↑
  • PVR ±
5–10 mgRepeated doses less effective (tachyphylaxis)
DopamineDA1, DA2RBF ↑↑200 mg800 μg/mL0.5–3 (“renal” dose)
β1, β2
  • HR ↑↑
  • MAP ↑
  • CO ↑↑
  • PVR –
400 mg1.6 mg/mL3–10 (β dose)
α1, α2, β1, β2
  • HR ↑↑
  • MAP ↑↑
  • CO ↑↑
  • PVR ↑↑
800 mg3.2 mg/mL10–20 (α + β)
Fenoldopam (Corlopam®)DA1
  • HR image
  • MAP ↓
  • CO ↑
  • PVR ↓↓
10 mg40 μg/mL
  • 0.1
  • Increase by 0.1 q15–20 min until target MAP reached
Renal vasodilator
Dobutamine (Dobutrex®)β1, weak β2
  • HR ↑
  • MAP ↑
  • CO ↑↑
  • PVR ↓
250 mg1 mg/mL2–30
Isoproterenol (Isuprel®)β1, β2
  • HR ↑↑
  • MAP ↓
  • CO ↑↑
  • PVR ↓↓
2 mg8 μg/mL0.01–0.5Photosensitive
Other
Vasopressin (arginine vasopressin, Pitressin®)
  • HR 0
  • MAP ↑↑
  • CO ↓
  • PVR –
100 U in 100 mL1 U/mL0.1–0.4 U/min
Milrinone (Primacor®)Phosphodiesterase inhibitor
  • HR –↑
  • MAP 0
  • CO ↑↑
  • PVR ↓↓
50 mg200 μg/mL0.375–0.75N/A
Inamrinone (Inocor®)Phosphodiesterase inhibitor
  • HR –↑
  • MAP 0
  • CO ↑↑
  • PVR ↓↓
100 mg0.4 mg/mL5–100.75 μg/kg (load)
Levosimendan (Simdax®)Weak PDE inhibitor, mainly calcium sensitizer
  • CO ↑↑
  • SV ↑↑
  • MAP ↓
  • PVR ↓
12.5 in 500 mL of D50.025 mg/mL0.05–2 μg/kg/minPhotosensitive, but does not need to be kept from light during infusion
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Medications Used to Lower the Blood Pressure
DrugsIV infusion (μg/kg/min)Dilution (in 250 mL)Final concentrationBolus (if applicable)Special precautions/comments
Vasodilators
Nitroglycerin0.1–750 mg200 μg/mL50–100 μg
Nitroprusside (Nipride®)0.1–1050 mg200 μg/mL

Photosensitive, protect from light during infusion

Can result in:

• Thiocyanate toxicity (slurred speech, dizziness, stupor)

• Cyanide toxicity (metabolic acidosis, tachyphylaxis, increased MVO2)

Fenoldopam (Corlopam®)0.1–0.210 mg40 μg/mL
Hydralazine (Apresoline®)2.5–20 mgTakes 15 ...

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