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