Pharmacological treatment

If hypotension persists after an adequate circulating volume, rate and rhythm has been restored, the appropriate choice of drug treatment depends on whether there is myocardial failure (signs of low output or measured low stroke volume) or peripheral vascular failure (warm, vasodilated periphery or measured normal stroke volume). A low stroke volume should be treated with an inotrope (e.g. epinephrine, dobutamine) and peripheral vascular failure with a vasopressor (e.g. norepinephrine).

Inotropic support

Epinephrine (started at 0.2pg/kg/min), dopamine or dobutamine (started at 5pg/kg/min) should be titrated against stroke volume (if monitored). Most hypotensive patients requiring inotropes should have a pulmonary artery catheter inserted. The alternative is to titrate against blood pressure, but there is a danger of producing inappropriate vasoconstriction. Dobutamine is safer in this respect but has the disadvantage of producing excessive vasodilatation in some patients.

Vasopressors

Once stroke volume has been optimised, norepinephrine (started at 0.05pg/kg/min) should be titrated against mean BP. In most patients, with previously normal blood pressure, 60mmHg is an adequate target but may need to be higher to ensure organ perfusion in the elderly and those with previous hypertension. Norepinephrine may reduce cardiac output. This effect should be monitored and corrected by adjustment of dose. Vasopressin (or its synthetic analogue, terlipressin) is increasingly used for high output, catecholamine-resistant, vasodilatory shock. Care should be taken to avoid excessive peripheral constriction or impairment of organ perfusion.

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