Vasopressors and Inotropes

Topic Progress:

Pearls for Vasopressors and Inotropes

1. The goal for these medications is to increase blood pressure to to move oxygen supply to organs.
2. Vasopressors squeeze blood vessels.
3. Inotropes squeeze the heart.

Vasopressors and Intropes for COVID-19

Without getting lost in the weeds, most patients with COVID-19 typically need some blood pressure support because of concurrent treatment side effects, such as sedation and analgesia.
Alternatively, some patients require blood pressure support because they are so sick that their normal compensatory mechanisms are disrupted, such as in septic or cardiogenic shock.

Tips and Tricks

MAP >65 is the Usual Blood Pressure Goal

A blood pressure MAP >65 is typically the goal1 to aim for until listed otherwise by your ICU team, so it’s a good place to start.

The Drug of Choice

Norepinephrine is the drug of choice to increase blood pressure because of its documented safety2-3 and its ease to titrate.

General Framework for Vasopressors

Definitions

  • Contractility is the strength (or inotropy) of each heartbeat
  • Preload is the stretch of the right ventricle at the end of diastole
    • A surrogate measurement is the amount of volume in the right ventricle between diastole and systole
  • Afterload is the amount of vasoconstriction (vasopressor effect) the heart must push against when ejecting volume

Note that one important piece of oxygen supply is cardiac output, which is heavily dependent on stroke volume and heart rate.

Receptor Targets for BP Control

ReceptorHemodynamic EffectLocationCommon Uses
Alpha 1– Vasoconstriction
– Increase afterload
Pipes
– Arteries
– Veins
– Easy to titrate and safe
– Common first line medication for hypotension
– Sepsis
– Hypotension from fentanyl and propofol
Beta 1– Increase heart rate
– Increase inotropy (contractility)
Pump
– Myocytes (heart)
– Bradycardias
-Hypotensive states
-Sepsis
-Many low MAP pathologies
Beta 2– Bronchodilation
– Increase heart rate
– Lungs
– Some myocytes (heart)
-Bronchconstrictive states

References

1. Lamontagne F, Richards-Belle A, Thomas K, et al. Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial. JAMA. 2020;323(10):938–949. doi:10.1001/jama.2020.0930

2. Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Critical care medicine. 2012; 40(8):2479-85. PMID: 22809915

3. Parienti JJ, Mongardon N, Mégarbane B. Intravascular Complications of Central Venous Catheterization by Insertion Site. The New England journal of medicine. 2015; 373(13):1220-9. PMID: 26398070

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