Inotrope and Vasopressor Use in ICU

Introduction to Inotropes and Vasopressors

The American College of Cardiology recommends starting vasopressors when mean arterial pressure (MAP) remains <65 mmHg despite adequate fluid resuscitation, or immediately in life-threatening hypotension to prevent cerebral or coronary ischemia while continuing volume replacement 1, 2
The European Heart Journal suggests reserving inotropes for patients with severe reduction in cardiac output causing compromised vital organ perfusion, who are almost always hypotensive 4, 5, 3

Norepinephrine is the first-choice vasopressor for most shock states, with superior outcomes and fewer arrhythmias compared to dopamine, according to the European Heart Journal 6, 1, 2
Dobutamine is the first-choice inotrope for low cardiac output states, as recommended by the European Heart Journal 4, 5, 1
The starting dose of norepinephrine is 0.02 mcg/kg/min, with a titration range up to 0.1-0.2 mcg/kg/min, and a target MAP ≥65 mmHg, as suggested by Praxis Medical Insights 2, 1
The starting dose of dobutamine is 2-2.5 mcg/kg/min, with a titration range up to 20 mcg/kg/min, as recommended by the European Heart Journal 4, 5

Continuous monitoring of ECG, blood pressure, and oxygen saturation is recommended, as suggested by Praxis Medical Insights 1, 2, 4, 5
Frequent monitoring of urine output, serum lactate, arterial blood gases, mental status, and skin perfusion is also recommended, according to Praxis Medical Insights 1, 2

Arrhythmias are a common complication, with dobutamine carrying a higher risk (up to 25%) compared to norepinephrine (2-15%), as reported by Praxis Medical Insights 1, 3
Myocardial ischemia can occur, with an incidence of 1-4% for acute coronary events, and can be prevented by avoiding excessive tachycardia and monitoring for chest pain/ECG changes, as suggested by the European Heart Journal and Praxis Medical Insights 1, 4, 5, 3
Tissue ischemia and necrosis can also occur, with limb ischemia having a 2% incidence, and can be prevented by using central access, monitoring infusion site frequently, and assessing peripheral perfusion, as recommended by Praxis Medical Insights 1