Vasopressor and Inotrope Use in Canadian Emergency Departments: Evidence Based Consensus Guidelines

Thank you Dr Amit Maini for sharing this with us.

Published about a year ago in the CJEM. The article can be downloaded here and the executive summary here (both open access).

Executive Summary:

Strong Recommendations: 

• Cardiogenic shock patients in the ED should receive norepinephrine as the first-line vasopressor.
• Norepinephrine is the first line vasopressor for use in septic shock.
• Dobutamine should be used for septic shock with low cardiac output despite adequate volume resuscitation.
• Epinephrine infusion is the preferred agent for anaphylactic shock that does not respond to intramuscular or intravenous bolus epinephrine. 
• In undifferentiated shock not responding to fluid resuscitation, norepinephrine should be the first line vasopressor. 

Conditional Recommendations: 

• Cardiogenic shock patients in the ED should receive dobutamine if an inotrope is deemed necessary.
• Routine vasopressor use in hypovolemic shock is not recommended.
• Vasopressin may be indicated in hemorrhagic or hypovolemic shock if a vasopressor is deemed necessary.
• In obstructive shock not responding to indicated treatment, a systemically active vasopressor should be instituted.
• For patients with known or suspected hypertrophic obstructive cardiomyopathy (HOCM) or dynamic outflow obstruction, inotropic agents should be avoided. Judicious use of vasoconstrictive agents can be considered.
• Vasopressin should be considered in cathecholamine refractory septic shock.
• Vasopressor choice in neurogenic shock is not clear. The agent should be determined by patient characteristics and response to treatment. 
• Norepinephrine is the first line agent for the management of distributive shock due to hepatic failure.
• Vasopressor choice in distributive shock secondary to adrenal insufficiency not responding to steroid replacement is not clear. Patient response to chosen agents should guide therapy. 
• In undifferentiated shock, a second vasopressor should be added if a goal MAP > 70 mmHg is not being achieved.
• Short term vasopressor infusions (<1-2 hours) or boluses via properly positioned and functioning peripheral intravenous catheters are unlikely to cause local complications.
• Vasopressor infusions for prolonged periods (>2-6 hours) should preferentially be administered via central venous catheters.
• Inotropes can be given via peripheral catheter (short term) or central venous catheters (prolonged period) with a similarly low incidence of local complications.
  The administration of vasopressors via intra-osseous lines is safe in adults.

Djogovic et al Vasopressor and Inotrope Use in Canadian Emergency Departments: Evidence Based Consensus Guidelines, CJEM 2015