| Agent | United States trade name | Initial dose | Usual maintenance dose range | Range of maximum doses used in refractory shock | Role in therapy and selected characteristics |
| Vasopressors (alpha-1 adrenergic) |
| Norepinephrine (noradrenaline) | Levophed | 5 to 15 mcg/minute (0.05 to 0.15 mcg/kg/minute) Cardiogenic shock: 0.05 mcg/kg/minute | 2 to 80 mcg/minute (0.025 to 1 mcg/kg/minute) Cardiogenic shock: 0.05 to 0.4 mcg/kg/minute | 80 to 250 mcg/minute (1 to 3.3 mcg/kg/minute) | - Initial vasopressor of choice in septic, cardiogenic, and hypovolemic shock.
- Wide range of doses utilized clinically.
- Must be diluted; eg, a usual concentration is 4 mg in 250 mL of D5W or NS (16 micrograms/mL).
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| Epinephrine (adrenaline) | Adrenalin | 1 to 15 mcg/minute (0.01 to 0.2 mcg/kg/minute) | 1 to 40 mcg/minute (0.01 to 0.5 mcg/kg/minute) | 40 to 160 mcg/minute (0.5 to 2 mcg/kg/minute) | - Initial vasopressor of choice in anaphylactic shock.
- Typically an add-on agent to norepinephrine in septic shock when an additional agent is required to raise MAP to target and occasionally an alternative first-line agent if norepinephrine is contraindicated.
- Increases heart rate; may induce tachyarrhythmias and ischemia.
- For inotropy, doses in the higher end of the suggested range is needed.
- Elevates lactate concentrations during initial administration (ie, may preclude use of lactate clearance goal); may decrease mesenteric perfusion.
- Must be diluted; eg, a usual concentration is 1 mg in 250 mL D5W (4 micrograms/mL).
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| Phenylephrine | Neo-Synephrine, Vazculep | 40 to 160 mcg/minute until stabilized (alternatively, 0.5 to 2 mcg/kg/minute) | 20 to 400 mcg/minute (0.25 to 5 mcg/kg/minute) | 80 to 730 mcg/minute (1.1 to 9.1 mcg/kg/minute) | - Pure alpha-adrenergic vasoconstrictor.
- May be considered when tachyarrhythmias preclude use of norepinephrine.
- Alternative vasopressor for patients with septic shock who: (1) develop tachyarrhythmias on norepinephrine, epinephrine, or dopamine, (2) have persistent shock despite use of two or more vasopressor/inotropic agents including vasopressin (salvage therapy), or (3) high cardiac output with persistent hypotension.
- May decrease stroke volume and cardiac output in patients with cardiac dysfunction.
- May be given as bolus dose of 50 to 100 mcg to support blood pressure during rapid sequence intubation.
- Must be diluted. The usual concentration is 10 mg in 250 mL D5W or NS (40 mcg/mL). Others include the following based upon volume status: 10 mg in 500 mL (20 mcg/mL) of D5W or NS, 50 mg in 500 mL (100 mcg/mL) of NS, 100 mg in 500 mL (200 mcg/mL) of NS, or 100 mg in 250 mL (400 mcg/mL) of NS.
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| Dopamine | Inotropin | 2 to 5 mcg/kg/minute | 2 to 20 mcg/kg/minute | 20 mcg/kg/minute | - An alternative to norepinephrine in septic shock in highly selected patients (eg, with absolute or relative bradycardia and a low risk of tachyarrhythmias).
- More adverse effects (eg, tachycardia, arrhythmias particularly at doses ≥20 mcg/kg/minute) and less effective than norepinephrine for reversing hypotension in septic shock.
- Lower doses (eg, 1 to 3 mcg/kg/minute) should not be used for renal protective effect and can cause hypotension during weaning.
- Must be diluted (eg, a usual concentration is 400 mg in 250 mL D5W [1.6 mg/mL] or 800 mg in 250 mL D5W [3.2 mg/mL]); use of a commercially available pre-diluted solution is preferred.
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| Antidiuretic hormone |
| Vasopressin (arginine-vasopressin) | Pitressin, Vasostrict | 0.03 units/minute | 0.01 to 0.04 units/minute (not titrated) | Doses >0.04 units/minute can cause cardiac ischemia and should be reserved for salvage therapy | - Add-on to norepinephrine to raise blood pressure to target MAP or decrease norepinephrine requirement. Not recommended as a replacement for a first-line vasopressor.
- Pure vasoconstrictor; may decrease stroke volume and cardiac output in myocardial dysfunction or precipitate ischemia in coronary artery disease.
- Must be diluted; eg, a usual concentration is 25 units in 250 mL D5W or NS (0.1 units/mL).
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| Inotrope (beta1 adrenergic) |
| Dobutamine | Dobutrex | Usual: 2 to 5 mcg/kg/minute (range: 0.5 to 5 mcg/kg/minute; lower doses for less severe cardiac decompensation) | 2 to 10 mcg/kg/minute | 20 mcg/kg/minute | - Initial agent of choice in cardiogenic shock with low cardiac output and maintained blood pressure.
- Add-on to norepinephrine for cardiac output augmentation in septic shock with myocardial dysfunction (eg, in elevated left ventricular filling pressures and adequate MAP) or ongoing hypoperfusion despite adequate intravascular volume and use of vasopressor agents.
- Increases cardiac contractility and rate; may cause hypotension and tachyarrhythmias.
- Must be diluted; a usual concentration is 250 mg in 500 mL D5W or NS (0.5 mg/mL); use of a commercially available pre-diluted solution is preferred.
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| Inotrope (nonadrenergic, PDE3 inhibitor) |
| Milrinone | Primacor | 0.125 to 0.25 mcg/kg/minute | 0.125 to 0.75 mcg/kg/minute | 0.75 mcg/kg/minute | - Alternative for short-term cardiac output augmentation to maintain organ perfusion in cardiogenic shock refractory to other agents.
- Increases cardiac contractility and modestly increases heart rate at high doses; may cause peripheral vasodilation, hypotension, and/or ventricular arrhythmia.
- Renally cleared; dose adjustment in renal impairment needed.
- Must be diluted; eg, a usual concentration is 40 mg in 200 mL D5W (200 micrograms/mL); use of a commercially available pre-diluted solution is preferred.
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