Quick Reference
Vasopressor Guide
First-line agents, receptor profiles, dosing, and when to escalate. Know your pressors cold -you'll be titrating them at 3 AM.
Vasopressor Table
| Agent | Dose | Receptor | Role | Avoid / Caution |
|---|---|---|---|---|
| Norepinephrine (Levophed) 1ST LINE | 0.01–3 mcg/kg/min | α₁>>β₁ | First-line in septic shock: strong recommendation over dopamine, epinephrine and selepressin (SSC 2026). Only the head-to-head against vasopressin or angiotensin II is a conditional "suggest", so do not read that as a general downgrade of NE. ↑ SVR + mild inotropy. SSC, 2026 | - |
| Vasopressin (Vasostrict) ADD-ON | 0.03 units/min (fixed, no titration) | V1/V2 | Add-on to NE (NE-sparing). May reduce AKI. Add when NE ≥ 0.25–0.5 mcg/kg/min. VASST, 2008 | Coronary vasospasm, mesenteric ischemia at higher doses |
| Epinephrine (Adrenalin) 2ND LINE | 0.01–0.5 mcg/kg/min | α₁, β₁, β₂ | Refractory shock. Strong inotropy + vasoconstriction. Also cardiac arrest. | Falsely elevates lactate (β₂-mediated aerobic glycolysis) -can't use lactate to guide resuscitation |
| Phenylephrine (Neo-Synephrine) 3RD LINE | 0.5–6 mcg/kg/min | α₁ pure | Use if tachyarrhythmia limits NE use. Pure vasoconstriction. | Low CO states (no inotropy -worsens cardiac output) |
| Dobutamine (Dobutrex) INOTROPE | 2–20 mcg/kg/min | β₁>β₂ | Low CO despite adequate MAP (cardiogenic component). Not a vasopressor -an inotrope. | Never use alone if MAP < 65 (drops SVR via β₂). Always pair with NE. |
| Milrinone (Primacor) INOTROPE | 0.125–0.75 mcg/kg/min | PDE3 inhibitor | Inodilator. RV failure, pulmonary HTN, post-cardiac surgery. Inotropy + ↓ PVR. | Hypotension (vasodilation). Renally cleared -dose-adjust in AKI. |
| Angiotensin II (Giapreza) LAST RESORT | 20–200 ng/kg/min | AT1 receptor | Catecholamine-refractory vasodilatory shock. ATHOS-3, 2017 | Thrombosis risk. Very expensive. Last-line agent. |
| Dopamine (Intropin) AVOID | 2–20 mcg/kg/min | D1, β₁, α₁ (dose-dependent) | AVOID in sepsis. More arrhythmias, higher mortality vs NE. SOAP II, 2010 | Avoid. Only remaining role: symptomatic bradycardia if no pacing available. |
Adjuncts
| Drug | Indication | Dose | Evidence |
|---|---|---|---|
| Hydrocortisone (Solu-Cortef) | Refractory septic shock with ongoing vasopressor requirement | 200 mg/day IV (50 mg q6h or continuous infusion) | ADRENAL, 2018: faster shock reversal, no mortality benefit. APROCCHSS, 2018: 90-day mortality benefit in the overall randomized population (43.0% vs 49.1%), not a subgroup. Its patients were sicker than ADRENAL's (all in shock ≥ 6h on high-dose pressors, and it added fludrocortisone), which is the leading explanation for why the two trials diverged. |
| Methylene blue (ProvayBlue) | Vasoplegia (post-cardiac surgery, refractory distributive shock) | 1–2 mg/kg IV bolus, may repeat or infuse 0.5 mg/kg/hr | Case series. Inhibits soluble guanylate cyclase (and, less importantly, NO synthase), blocking the NO → cGMP pathway that keeps vascular smooth muscle relaxed in vasoplegia → restores SVR. Rescue agent. |
| Thiamine (Vitamin B1) | Suspected deficiency (alcoholism, malnutrition, refeeding) | 200–500 mg IV q8h × 3 days | Prevents Wernicke's. May help refractory lactic acidosis. |
Escalation Ladder
Stepwise approach to vasopressor escalation in septic shock:
Step 1
Norepinephrine (Levophed) -first-line. Start at 0.05 mcg/kg/min, titrate to MAP ≥ 65.
Step 2
Add vasopressin (Vasostrict) 0.03 u/min when NE ≥ 0.25–0.5 mcg/kg/min. Fixed dose, NE-sparing.
Step 3
Start hydrocortisone (Solu-Cortef) 200 mg/day if still on escalating vasopressors with ongoing requirement. SSC, 2026
Step 4
Add epinephrine (Adrenalin) if refractory. Provides additional inotropy. Watch for lactate confounding.
Step 5
Consider angiotensin II (Giapreza) ATHOS-3, 2017 or methylene blue (ProvayBlue) for catecholamine-refractory vasoplegia. Reassess: is source controlled? Missed adrenal crisis? Cardiac tamponade?
Key Pearls
Never run dopamine in sepsis. SOAP II, 2010: no overall mortality difference (48.5% vs 52.5%, p = 0.10), but double the arrhythmia rate (24.1% vs 12.4%) and higher mortality in the cardiogenic shock subgroup. It is the arrhythmia burden, not a survival signal, that makes NE the better first choice. There is no "renal-dose dopamine."
Epinephrine falsely elevates lactate via β₂-mediated aerobic glycolysis. If you're on epi, you cannot use lactate clearance to guide resuscitation.
Vasopressin is fixed-dose 0.03 u/min. Do not titrate. It's an add-on, not a standalone. Wean NE first, then vaso last.
Dobutamine ≠ vasopressor. It's an inotrope. If MAP is low, you need NE first. Add dobutamine only if MAP is adequate but CO is low (cold extremities, poor ScvO₂ despite adequate MAP).
Key Trials
| Trial | Year | Finding |
|---|---|---|
| SOAP II | 2010 | NE vs dopamine in shock (n = 1,679): no difference in 28-day mortality (48.5% NE vs 52.5% dopamine, p = 0.10). Dopamine caused twice the arrhythmias (24.1% vs 12.4%, p < 0.001) and had higher mortality in the cardiogenic shock subgroup only. The arrhythmia signal, not a mortality signal, is why NE is first-line. |
| VASST | 2008 | Vasopressin + NE vs NE alone: no overall mortality difference, but possible benefit in less severe shock |
| VANISH | 2016 | Vasopressin vs NE as first-line: no difference. Vasopressin may reduce need for RRT. |
| ADRENAL | 2018 | Hydrocortisone in septic shock: faster shock reversal, no 90-day mortality benefit |
| APROCCHSS | 2018 | Hydrocortisone + fludrocortisone: 90-day mortality benefit in severe septic shock |
| ATHOS-3 | 2017 | Angiotensin II in vasodilatory shock: improved MAP response vs placebo |
