VASOPRESSORS

Question 1

NOREPINEPHRINE

Answer 1

MIX
4 mg OR 8 mg in 250 ml saline = 16 ug / ml or 32 ug / ml

INFUSION RATE
0.05 - 0.5 ug / kg / min ~ (0.1-0.3 most common), if BP in boots (SBP 70 start at 0.3)

titrate by 0.02 μg/kg/minute every 5 minutes

OR
5 - 20 ug / min

BOLUS
16 mcg (1 ml) at 4 mg / 250 ml

Question 2

VASOPRESSIN

Answer 2

INDICATION
Rescue during inflammatory shock (sepsis)

MIX
40 U in 100 ml NS
(0.4 U / ml)

INFUSION
0.02-0.1 U/min
Or
6 cc / hr

BOLUS
1 U per 3 min

Question 3

EPINEPHRINE

Answer 3

INDICATIONS
VF / Pulsess VT
PEA / Asystole
Bradycardia (infusion)
Post Cardiac Arrest (infusion)
Anaphylaxis

BOLUS DOSING: CARDIAC ARREST
1 mg IV q 3-5 min

BEDSIDE EPINEPHRINE MIX
1 mg (1000 mcg) Epi into 1 L 0.9% NS
Sterile Technique
Label 1 mcg / mL

Start 1 - 2 mL / min (1-2 mcg / min) titrate to effect

Typical macro drip: 20 drops per mL

1 drop / sec = 60 drop / min = 3 mL / min = 3 mcg / min

Preferrably use smart pump

Alternate Mix (HSN):
4 mg epinephrine is mixed with 250ml of NS or D5W = 16 ug / ml

INFUSION DOSING: BRADYCARDIA

Weight Based:
0.01-0.5 mcg/kg/min
Usual 0-0.3 mcg/kg/min

OR

Fixed:
2-10 micrograms/min (titrated to effect)

Typical macro drip: 20 drops per mL
1 drop / sec = 60 drop / min = 3 mL = 3 mcg / min

INFUSION DOSING: POST CARDIAC ARREST HYPOTENSION

Weight Based:
0.01-0.5 mcg/kg/min

Usual 0-0.3 mcg/kg/min

OR

Fixed:
2-10 micrograms/min

Typical macro drip: 20 drops per mL
1 drop / sec = 60 drop / min = 3 mL = 3 mcg / min

DOSING: ENDOTRACHEAL TUBE
2-2.5mg epinephrine is diluted in 10cc NS

Given directly into the ET tube.

BOLUS DOSING
10 ug every min at 1 mcg / ml (10 mL push)
OR
8 ug at 16 ug /ml (0.5 mL push)

ANAPHYLAXIS: INTRAMUSCULAR

> 50 kg: 0.5 mg IM Anteriorlateral Thigh (0.5 mL of 1:1000)

Children >30 kg 0.3 mg IM Anteriorlateral Thigh (0.3 mL of 1:1000)

Children 15-30 kg 0.15 mg IM Anteriorlateral Thigh

Children < 15 kg 0.01 mg / kg / dose (max 0.15 mg) IM Anteriorlateral Thigh

Repeat q 5 min PRN

If > 2-3 IM Epinephrine Doses or Severe Hypotension or Refractory Anaphylaxis, progress to Epinephrine Infusion

ANAPHYLAXIS: INFUSION

Weight-Based:
0.01-0.1 μg/kg/minute titrated by 0.01-0.05 μg/kg/minute every 2-3 minutes

Fixed Dose:
Start at 5 mcg / min (5 mL / min) titrate to effect

MONITORING
Continueous Cardiopulmonary monitoring
Blood Pressure monitor q 1-2 min
Monitor for ADRs:
Tachycardia
Cardiac Ischemia
Hypertension
Headache
Cardiac Arrest
Stroke

HALF LIFE
1-2 min

Question 4

PHENYLEPHRINE

Answer 4

Indications:

Treatment of Intra-Operative hypotension

Post RSI Hypotension

Mechanism of Action:

Direct agonist of a-adrenergic receptor

Mix:
10 mg in 100 ml of saline = 100 mcg / ml

Bolus Dose:

100 ug IV (1-2 cc bolus)

Duration
< 5 min

Reuptake by tissue, liver, gut (monoamine oxidase)

CVS Effects:
Vasoconstriction

Reflex Bradycardia

Question 5

DOBUTAMINE

Answer 5

INDICATIONS
Cardiogenic Shock
Severe Septic Shock

MIX
250 mg in 250 mL NS or D5W
(1000 mcg/mL)

INFUSION RATE
2 - 20 mcg / kg / min

ADRs
Vasodilation -> Risk of Hypotension

Question 6

DOPAMINE

Answer 6

INDICATIONS
Bradycardia

DOSING
400 mg in 250 ml D5W (1600 mcg/ml)

2-20 mcg / kg / min
Usual dosing 0-10 mcg/kg/min

Question 7

ISOPROTENEROL

Answer 7

INDICATIONS
Bradycardia

MIX
1 mg in 500 cc

DOSING
1 to 20 mcg/minute