Which medications in the drug class Vasopressors are used in the treatment of Septic Shock?

Updated: Jan 11, 2019
  • Author: Andre Kalil, MD, MPH; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM  more...
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Answer

Vasopressors

In cardiovascular disorders, vasopressors are used to elevate blood pressure. They induce vasoconstriction and elevate mean arterial pressure, as well as provide hemodynamic support in acute heart failure and shock.

Vasopressors are used as second-line agents in the treatment of septic shock. There is no evidence that one vasopressor is superior compared to the other.

Norepinephrine (Levophed)

Norepinephrine is used in protracted hypotension after adequate fluid replacement. It stimulates beta1- and alpha-adrenergic receptors, thereby in turn increasing cardiac muscle contractility and heart rate as well as vasoconstriction. As a result, it increases systemic blood pressure and cardiac output. Adjust and maintain the infusion to stabilize the blood pressure (eg, 80-100 mm Hg systolic blood pressure) sufficiently to perfuse vital organs.

Dopamine (Intropin)

Dopamine stimulates both adrenergic and dopaminergic receptors. Its hemodynamic effect depends on the dose. Lower doses stimulate mainly dopaminergic receptors that produce renal and mesenteric vasodilation. Higher doses produce cardiac stimulation and renal vasodilation. After therapy is initiated the dosage may be increased by 1-4 µg/kg/min every 10-30 minutes until a satisfactory response is attained. Maintenance dosages lower than 20 µg/kg/min are usually satisfactory for 50% of the patients treated.

Dobutamine

Dobutamine is a sympathomimetic amine with stronger beta than alpha effects. It produces systemic vasodilation and increases the inotropic state. Vasopressors augment the coronary and cerebral blood flow during the low-flow state associated with shock. Sympathomimetic amines with both alpha- and beta-adrenergic effects are indicated in cardiogenic shock.

Dobutamine is used in early goal-directed therapy if there is evidence that tissue hypoperfusion and myocardial dysfunction is related to sepsis. Dopamine and dobutamine are the drugs of choice for improving cardiac contractility, with dopamine the preferred agent in hypotensive patients. Higher dosages of dobutamine may cause an increase in heart rate, exacerbating myocardial ischemia.

Epinephrine (Adrenalin)

Epinephrine is used for hypotension that is refractory to dopamine or norepinephrine. It stimulates alpha- and beta-adrenergic receptors, resulting in relaxation of bronchial smooth muscle, increased cardiac output, and increased blood pressure.

Vasopressin (ADH, Vasostrict)

Vasopressin has vasopressor and antidiuretic hormone (ADH) activity. It increases water resorption at the distal renal tubular epithelium (ADH effect). Vasopressin promotes smooth muscle contraction throughout the vascular bed of the renal tubular epithelium (vasopressor effects). Vasoconstriction is increased in splanchnic, portal, coronary, cerebral, peripheral, pulmonary, and intrahepatic vessels.

Phenylephrine

Phenylephrine is a strong postsynaptic alpha-receptor stimulant with little beta-adrenergic activity. It produces vasoconstriction of arterioles and increased peripheral vascular resistance. This agent causes reflex myocardial depression and decreased heart rate; therefore, it must be used with caution. Phenylephrine is a first-line agent in patients with hypotension and extreme tachycardia. It can be used as an adjunct to norepinephrine or dopamine to augment peripheral vasoconstriction.

Synthetic human angiotensin II (Giapreza)

Angiotensin II, the major bioactive component of the renin-angiotensin-aldosterone system (RAAS), serves as one of the body’s central regulators of blood pressure. It raises blood pressure by vasoconstriction and increased aldosterone release; direct action of angiotensin II on the vessel wall is mediated by binding to the G-protein–coupled angiotensin II receptor type 1 on vascular smooth muscle cells, which stimulates Ca2+/calmodulin-dependent phosphorylation of myosin and causes smooth muscle contraction. It is indicated for adults with septic or other distributive shock.


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