Tina Vinsant, RN, host of the podcast Good Nurse Bad Nurse, joins us for a run through of all the major vasoactive agents given in the hospital. We minimized the jargon and maximized on practical cases, so join us for a memorable discussion of this fundamental subject.
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Phenylephrine
- AKA: Neosynephrine, “Neo”
- Pure α1 adrenergic agonist, increases SVR
- Has no inotropic effect
- What kind of patients do we see on this drip? Why?
- Surgical patients being treated for anesthesia associated hypotension
- Neurogenic shock, usually spinal cord injury
- Notable SE: reflexive bradycardia
- Drug interactions
- MAOIs, tricyclic antidepressants, linezolid (enhanced HTN effect)
- Acetaminophen: may increase serum concentration of phenylephrine
- Fentanyl – may decrease serum concentration of Fentanyl; onset effect of fentanyl may be delayed
Norepinephrine
- AKA: Levophed, “Levo”, Norepi
- α1, α2, β adrenergic agonist. Used for multifactorial problems, like sepsis
- Vasoconstriction effects greater than inotropic and chronotropic effects, but inotropic effects can help some with CO
- Extravasation can cause ischemic tissue necrosis/sloughing (tx: phentolamine)
- Notable SE: Decreased splanchnic and renal flow
- Do not administer in same line as bicarb
- Drug interactions
- MAOIs, SSRI/SNRI, Linezolid, tricyclic antidepressants (may enhance hypertensive effect)
Epinephrine
- AKA: Epi, Adrenalin
- What kind of patients do we see on this drip? Why?
- Anaphylaxis because it mimics our endogenous adrenalin
- Adjunct to norepinephrine in septic shock
- α1, α2, β1, β2 agonists: Increased SVR, inotropy and chronotropy
- Notable SE: Can induce splanchnic (organs of the abdomen) flow, arrhythmia, Increases lactate levels and blood glucose
Dopamine
- AKA: Dopa
- Primary impact
- Low dose: Increased inotropy and heart rate
- Higher dose: Increased SVR and inotropy
- Notable SE: Tachyarrhythmias
- Drug interactions: MAOIs, Linezolid, SSRI/SNRI, tricyclic antidepressants (enhanced hypertensive effect)
Dobutamine
- Positive lusitropic (myocardial relaxation), inotropic (contractility), & chronotropic (heart rate) effects
- Tachyphylaxis w/ infusions > 72 hrs (diminishing effect of drug despite increasing dosage)
- Can cause vasodilation
- Minimal alpha effects
- Decreases SVRIncreases CO
- Most commonly used for severe HF and cardiogenic shock
Milrinone
- What kind of patients do we see on this drip? Why?
- Advanced HF
- Bridge therapy
- Palliative
- Does not work on adrenergic receptors
- Phosphodiesterase III inhibitor. Phosphodiesterase III is present in the cardiac sarcoplasmic reticulum, smooth muscle in arteries and veins.
- Positive inotropy, positive lusitropy, and vasodilation
- Similar to dobutamine with few SE
Vasopressin
- This drug is not vasoactive drug – it increases BP by increasing blood volume
- Vasopressin is indicated to increase blood pressure in adults in vasodilatory shock refractory to the application of fluids and catecholamines.
Midodrine
- PO!
- Midodrine is an alpha agonist and acts as a peripheral vasoconstrictor
Suggested Read
ALiEM: Choosing the right vasopressor agent in hypotension