ICU · Pharmacology
ICU vasopressor and inotrope pharmacology — comprehensive (catecholamines, vasopressin, inodilators)
Also known as Noradrenaline (norepinephrine) · Adrenaline (epinephrine) · Vasopressin · Dobutamine · Milrinone · Dopamine · Phenylephrine · Metaraminol · Levosimendan · Angiotensin II · SOAP II trial · VASST trial · VANISH trial · SEPSISPAM trial · CAT trial · Annane adrenaline trial (Lancet 2007) · Vasopressor weaning
Vasopressors increase blood pressure (vasoconstriction) and inotropes increase cardiac output (contractility). First-line vasopressor in septic shock: NORADRENALINE — Surviving Sepsis 2021 strong recommendation (alpha-1 vasoconstriction with modest beta-1, minimal heart-rate effect). CAT (Myburgh 2008) and Annane (Lancet 2007) showed adrenaline is equivalent for mortality but carries transient metabolic (lactate) effects. Add vasopressin at a FIXED 0.03 U/min (V1 receptor, catecholamine-sparing per VASST/VANISH) instead of escalating noradrenaline when the dose reaches 0.25-0.5 mcg/kg/min. Adrenaline is the third-line add-on. Dobutamine for cardiac dysfunction with persistent hypoperfusion. Dopamine is not preferred: SOAP II found more arrhythmias (24.1% vs 12.4%) and no renal protection from low-dose dopamine (Bellomo 2000).
Checked against its sources on 1 Sept 2026
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Red flags
- Noradrenaline is FIRST-LINE in septic shock — SSC 2021 strong recommendation; adrenaline or dopamine only where noradrenaline is unavailable
- Dopamine is NOT preferred in septic shock — SOAP II: arrhythmias 24.1% vs 12.4% and a cardiogenic-shock subgroup signal of higher mortality
- Vasopressin is a FIXED-DOSE 0.03 U/min adjunct, not titrated — SSC 2021: add it instead of escalating noradrenaline (catecholamine-sparing, VASST/VANISH)
- Higher vasopressin doses (trials used up to 0.06 U/min) are associated with cardiac, digital and splanchnic ischaemia — SSC 2021
- Extravasation of vasopressors causes tissue ischaemia — intradermal phentolamine is the standard antidote (Reynolds 2014)
- Adrenaline increases lactate via beta-2-mediated aerobic lactate production (SSC 2021) — do not confuse with worsening sepsis
- Milrinone has an elimination half-life of about 2 h (Edelson 1986) — vasodilatory effects outlast stopping the infusion; higher loading doses increased norepinephrine requirements (De Hert 1995)
- During recovery, vasopressor infusions are tapered by protocol, not stopped abruptly (VASST tapered all infusions to maintain target blood pressure)
Meet the patient
A 66-year-old man in septic shock from a biliary source has had his fluid bolus and broad-spectrum antibiotics, yet his MAP is 58, lactate climbing, peripheries mottled, and his urine has slowed to a trickle.[1]
The question that decides his next hour is the one every fellowship exam asks: which pressor, in what order, and why? Hold the ladder — noradrenaline first, vasopressin fixed, adrenaline later, dopamine not preferred — and every escalation below slots into place.[1]
References33ShowHide
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