Medications to Raise Blood Pressure in Hypotension

First-Line Medications for Hypotension

The American College of Critical Care Medicine recommends norepinephrine as the first-choice vasopressor for treating hypotension, especially in septic shock, due to its reliable blood pressure elevating effects and moderate quality evidence supporting its use 1, 2, 3
Norepinephrine is typically infused at a rate of 0.2-1.0 μg/kg/min for hypotension, particularly in septic shock 4, 5
Epinephrine can be added to or substituted for norepinephrine when additional blood pressure support is needed, with a dosing range of 0.05-0.5 μg/kg/min 1
Dopamine should be used only in highly selected patients with low risk of tachyarrhythmias or those with relative bradycardia, with dosing at >5 μg/kg/min providing vasopressor effects 1, 4
Vasopressin can be added to norepinephrine (up to 0.03 U/min) to either raise mean arterial pressure or decrease norepinephrine dosage requirements 1, 3

In cardiogenic shock with hypotension, inotropes may be needed alongside vasopressors, as recommended by the European Heart Journal 6, 4
In hypovolemic shock, fluid resuscitation should precede vasopressor therapy, according to the American College of Critical Care Medicine 1, 2

Dobutamine can be used at 2-20 μg/kg/min when there is evidence of persistent hypoperfusion despite adequate fluid loading and vasopressor use, as recommended by the European Heart Journal 4, 3
Milrinone, a phosphodiesterase inhibitor, can be used at 0.375-0.75 μg/kg/min, particularly useful when beta-blockade is contributing to hypotension 4, 5
Levosimendan can be used at 0.1 μg/kg/min (range 0.05-0.2 μg/kg/min) for patients with cardiogenic shock, as recommended by the European Heart Journal 4, 5

In pediatric patients with fluid-refractory shock, dopamine is often the first-line vasopressor, according to the American College of Critical Care Medicine 8, 7
For catecholamine-resistant shock in children, norepinephrine plus dobutamine or enoximone can be considered, as recommended by the American College of Critical Care Medicine 7, 9
Corticosteroids (hydrocortisone) can be used for potential relative adrenal insufficiency in refractory shock, as recommended by the American College of Critical Care Medicine 7

Close monitoring of ECG and blood pressure is essential when using inotropes and vasopressors due to risks of arrhythmias, myocardial ischemia, and hypotension, as recommended by the European Heart Journal 4, 10
Arterial catheterization should be considered for all patients requiring vasopressors, according to the American College of Critical Care Medicine 1, 3