Inotropes and Vasopressors in Critically Ill Patients

Introduction to Inotropes and Vasopressors

The European Society of Cardiology recommends that inotropes increase cardiac contractility and cardiac output, while vasopressors increase vascular tone and blood pressure through vasoconstriction 1

The American College of Critical Care Medicine suggests that if hypotension (SBP <90 mmHg) with adequate cardiac output, use vasopressors, and if adequate blood pressure but low cardiac output with signs of hypoperfusion, use inotropes 1, 3
The Society of Critical Care Medicine recommends that if both hypotension AND low cardiac output, combine vasopressor with inotrope 3, 4

The European Society of Intensive Care Medicine recommends norepinephrine as the first choice for most shock states, with a dose titrated from 2-4 μg/min to effect, and an arrhythmia risk of 2-15% 2, 3
The American Heart Association suggests dobutamine as the first choice for low cardiac output, with a dose of 2.5-20 μg/kg/min, and an arrhythmia risk of up to 25% 1, 3, 4

The European Society of Cardiology recommends continuous monitoring of ECG, blood pressure, and oxygen saturation, as well as frequent monitoring of urine output, serum lactate, and arterial blood gases 1, 2, 4

The Society of Critical Care Medicine reports that arrhythmias are the most frequent complication (2-25% depending on agent), and ischemia is also a common adverse event (1-4% for acute coronary events, 2% for limb ischemia, and 0.6-4% for intestinal ischemia) 2

The American College of Critical Care Medicine advises to never use inotropes for renal protection, never target supranormal cardiac output, and never use vasopressors before adequate volume resuscitation, except as an emergency measure for cerebral/coronary perfusion 3, 5
The European Society of Intensive Care Medicine recommends to avoid high-dose dopamine due to excessive arrhythmia risk, and to wean vasopressin after norepinephrine to prevent hemodynamic instability 2