Contraindications and Precautions for Inotropes and Vasopressors in Shock

General Principles

Inotropes and vasopressors should not be used as first-line therapy in shock states except when there is severe hypotension with evidence of inadequate organ perfusion despite adequate fluid resuscitation, as recommended by the European Society of Cardiology 1, 2, 3
Uncorrected hypovolemia is a contraindication for vasopressors and inotropes, which should not be used before adequate fluid resuscitation, particularly in hypovolemic shock, according to the Society of Critical Care Medicine 2, 4, 5
Tachyarrhythmias are a contraindication for high-dose dopamine and epinephrine, as stated by the European Heart Journal 2, 6

Norepinephrine is not recommended as a first-line agent in cardiogenic shock unless other inotropes and fluid challenge have failed, as per the European Journal of Heart Failure 3, 7
Dopamine is contraindicated in patients with tachyarrhythmias, and its use should be restricted to highly selected patients with low risk of tachyarrhythmias or those with relative bradycardia, according to the Society of Critical Care Medicine 2, 8
Epinephrine should not be used as an inotrope or vasopressor in cardiogenic shock and should be restricted to use as rescue therapy in cardiac arrest, as recommended by the European Journal of Heart Failure 3
Phenylephrine is not recommended in septic shock except in specific circumstances, such as when norepinephrine is associated with serious arrhythmias, as stated by the Society of Critical Care Medicine 2, 8
Vasopressin should not be used as the single initial vasopressor for treatment of sepsis-induced hypotension, according to the Society of Critical Care Medicine 8

In cardiogenic shock, vasopressors should not be used as first-line agents and are only indicated when the combination of an inotropic agent and fluid challenge fails to restore systolic blood pressure >90 mmHg, as per the European Journal of Heart Failure 3, 7
In septic shock, low-dose dopamine should not be used for renal protection, and phenylephrine is not recommended except in specific circumstances, according to the Society of Critical Care Medicine 2, 8
In hemorrhagic shock, vasopressors should not be used before adequate volume resuscitation and control of bleeding, as stated by the Praxis Medical Insights 4

Inotropes and vasopressors should not be used without appropriate monitoring, including ECG monitoring, blood pressure monitoring, and assessment of tissue perfusion, as recommended by the European Heart Journal and the Society of Critical Care Medicine 6, 8
A practical algorithm for vasopressor/inotrope use in shock includes ensuring adequate fluid resuscitation before initiating vasopressors/inotropes, starting with norepinephrine as first-line vasopressor in septic shock, and using an inotrope in cardiogenic shock if systolic blood pressure remains low after fluid challenge, according to the Society of Critical Care Medicine and the European Journal of Heart Failure 2, 3, 7