Episode 188: Vasopressors
We go over the essential and complex topic of vasopressors in the ED. Hosts: Brian Gilberti, MD Catherine Jamin, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Vasopressors.mp3 Download Leave a Comment Tags: Critical Care Show Notes Introduction * Host: Brian Gilberti, MD * Guest: Catherine Jamin, MD * Associate professor of Emergency Medicine at NYU Langone Health * Vice Chair of Operations * Triple-boarded in Emergency Medicine, Internal Medicine, and Critical Care Medicine * Topic: Vasopressors: Essential agents for supporting critically ill patients in the ED What Are Vasopressors and When to Use Them * Two primary mechanisms to increase blood pressure: * Increasing systemic vascular resistance via vasoconstriction * Increasing cardiac output via augmenting inotropy and chronotropy * Indicators for vasopressor use: * MAP <65, systolic BP <90, or significant drop from baseline BP * Signs of organ dysfunction like altered mental status, decreased urine output, elevated lactate * Fluid resuscitation either ineffective or contraindicated (e.g., in CHF patients) Commonly Used Vasopressors in the ED * Norepinephrine * Epinephrine * Vasopressin * Phenylephrine Norepinephrine * Mechanism: Stimulates alpha-1 (vasoconstriction) and beta-1 receptors (increases inotropy & chronotropy) * Starting Dose: 10 mcg/min, titrate to MAP >65 * Max Dose: No strict limit but usually add a 2nd pressor at 15-20 mcg/min * Situational Preference: First-line for most cases of shock (septic, undifferentiated, hypovolemic, cardiogenic) * Pros: Can be infused peripherally via large bore IV Vasopressin * Mechanism: Activates V1a receptors causing vasoconstriction * Dose: Fixed, non-titratable dose of 0.04 units/min * Situational Preference: Second-line in septic shock * Concerns: Potential for peripheral ischemia Phenylephrine * Mechanism: Stimulates alpha-1 receptors causing vasoconstriction * Starting Dose: 100 mcg/min, titrate to MAP >65 * Situational Preference: High cardiac output states, tachyarrhythmias, peri-intubation * Concerns: Increases afterload, can worsen low cardiac output states Epinephrine * Mechanism: Stimulates alpha-1, beta-1 and beta-2 receptors * Starting Dose: 5-10 mcg/min, titrate to MAP >65 * Situational Preference: Anaphylactic shock, septic cardiomyopathy * Limitations: Can induce tachycardia, may elevate lactate levels Escalation Strategy in Refractory Shock * Norepinephrine -> Vasopressin (with stress dose steroids) -> Epinephrine * Consider POCUS, lactate, central venous saturation, and acid-base status