Vasoactive drugs in resuscitation

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• Noradrenaline is the first-line vasopressor for septic and most distributive shock — dopamine is no longer first-line because of the higher arrhythmia rate in SOAP II
• Anaphylaxis is treated with intramuscular adrenaline into the anterolateral thigh, not a vasopressor infusion — the dose is 0.5 mg of 1:1000, repeated every five minutes
• Vasopressin is a catecholamine-sparing adjunct, never a first-line pressor and never titrated above 0.04 units per minute — it carries a risk of mesenteric and digital ischaemia
• A peripheral vasopressor is acceptable as a temporising measure in the shocked patient who needs the pressure now — do not delay the pressor for the central line, but plan the central access early
• Extravasation of noradrenaline is an emergency — stop the infusion, aspirate, leave the cannula in situ, and inject phentolamine 5 to 10 mg in 10 mL saline subcutaneously around the site within twelve hours
• Milrinone is renally cleared — halve the dose in the acute kidney injury, and beware the refractory hypotension because the half-life is hours, not minutes
• Adrenaline raises the lactate through beta-2-driven aerobic glycolysis — a rising lactate on an adrenaline infusion is not by itself a sign of worsening shock