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Introduction
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You can stay ahead of the game, if you understand the impact sedation and intubation will have on your hypotensive patient and act to prevent it from happening in the first place.
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Learn More About Pressors
Start Early & Be Ready with Boluses
For patients in shock who need intubation, don’t delay pressors. Typically, start with an inopressor like norepinephrine and be ready with “push-dose” boluses of epinephrine or phenylephrine post-intubation for sudden pressure drops.
Graphic Overview
Pressors used during peri-intubation resuscitation have vasoconstrictive and/or inotropic effects. Some inotropes can have vasodilatory effects. Except in extremely select instances, these should never be used in the peri-intubation period.
Norepinephrine
Norepinephrine is a great all-rounder. It is often called an Inopressor because of its vasopressor and inotropic effects that lead to increased cardiac contractility and peripheral vasoconstriction. Other examples include Epinephrine and Dopamine.
Many institutions and pharmacy policies set limits on pressor rates. Norepinephrine is often set at a maximal dose of 30 mcg/min. Some have pumps that are physically unable to set it higher. There is no physiologic basis for this. Great individual variation occurs in the dose required to attain and maintain adequate blood pressure. In all cases, the dosage should be titrated according to the patient’s response.
epinephrine
At lower doses epinephrine has beta-agonist effects that predominate; with increasing doses it has increasing alpha-agonist effects. This makes it great for bradycardia and cariogenic shock. First-line agent for anaphylactic shock. Another great “push-dose” pressor in the peri-intubation period.
phenylephrine
A pure alpha-agonist that causes arterial and venous vasoconstriction. Often given in a “push-dose” for peri-intubation hypotension. Great for vasodilatory shock.
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References
- For a deeper dive into pressors, there’s no better place than the Internet Book of Critical Care. Another great FOAMED resource that you should add to your compendium to build your learning network.
- Also check out PulmCrit- High-dose vasopressors: Never surrender. June 4, 2018 by Josh Farkas
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