Page 184 - 2026 SMOG

VASOPRESSOR PRIORITY CHART
Hypovolemic Septic Cardiogenic Neurogenic Burn
Shock Shock Shock Shock Shock
1° Vasopressors are Norepinephrine Norepinephrine Norepinephrine Vasopressin
not recommended
in the initial
stabilization of
hypovolemic
shock
2° Norepinephrine Epinephrine Dobutamine 5 Vasopressin Norepinephrine
(add-on) (add-on)
3° Vasopressin Phenylephrine Epinephrine Epinephrine Epinephrine
(add-on)
• Vasopressors should only be initiated with/after adequate resuscitation is provided with
crystalloids, colloids, and/or blood products.
• Maintain mean arterial pressure (MAP) 65mmHg or as needed to achieve adequate endorgan
perfusion (e.g., cerebral perfusion pressure, abdominal perfusion pressure, urinary output).
1. Norepinephrine: Vasopressor of choice in septic, cardiogenic, and hypovolemic shock.
2. Epinephrine: Vasopressor of choice for Anaphylactic Shock. Used as an add-on agent to
norepinephrine in septic shock when an additional agent is required to raise MAP to target and
occasionally as an alternative first-line agent if norepinephrine is contraindicated.
3. Vasopressin: Add-on to norepinephrine to raise blood pressure to target MAP or decrease
norepinephrine requirement. Not recommended as a replacement for a first-line vasopressor.
4. Phenylephrine: Alternative vasopressor for patients with septic shock who: (1) develop
tachyarrhythmias on norepinephrine, epinephrine, or dopamine, (2) have persistent shock
despite use of two or more vasopressor/inotropic agents including vasopressin (salvage
therapy), or (3) have high cardiac output with persistent hypotension.
5. Dobutamine: Initial agent of choice in cardiogenic shock with low cardiac output and
maintained blood pressure. Add-on to norepinephrine for cardiac output augmentation in
septic shock with myocardial dysfunction (e.g., in elevated left ventricular filling pressures and
adequate MAP) or ongoing hypoperfusion despite adequate intravascular volume and use of
vasopressor agents.
6. Due to the physiologic nature of Neurogenic Shock, vasopressors may be initiated earlier to
avoid volume overload.

176 • MEDICATIONS