Vasopressor Comparison: Dopamine vs Norepinephrine vs Vasopressin — Receptor Selectivity and First-Line Use
Septic shock is tanking your patient's MAP and the provider orders a vasopressor — but picking the wrong one can worsen tachycardia, trigger dysrhythmias, or simply fail to raise perfusion pressure. Knowing which agent is first-line, which is dose-dependent, and which is the add-on separates a safe response from a dangerous delay.
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- Dose-dependent DA, β1, then α1 effects
- Potent α1 vasoconstriction + some β1
- ★Non-adrenergic V1 vasoconstriction
- Shock with bradycardia
- symptomatic ↓HR
- ★First-line for septic shock
- Adjunct in refractory septic shock
- Diabetes insipidus
- IV infusion
- titrate by mcg/kg/min to HR & BP
- IV infusion
- titrate up/down to MAP
- IV infusion
- fixed dose, not titrated
- Central line preferred (extravasation)
- Central line preferred (extravasation)
- Central line preferred (extravasation)
- Continuous BP/ECG
- monitor perfusion & urine output
- Continuous BP/ECG
- monitor perfusion & urine output
- Continuous BP/ECG
- monitor perfusion & urine output
- ★Tachydysrhythmias
- Peripheral ischemia
- Reflex bradycardia
- Peripheral ischemia
- No direct effect on HR
- Hyponatremia (water retention)
- Peripheral ischemia
- Extravasation can cause necrosis
- Antidote: phentolamine
- Extravasation can cause necrosis
- Antidote: phentolamine
- Extravasation can cause necrosis
- Phentolamine not effective
- Titrate to MAP ≥ 65
- Titrate to MAP ≥ 65
- Titrate to MAP ≥ 65
- Continuous ICU monitoring
- report IV site pain
- Continuous ICU monitoring
- report IV site pain
- Continuous ICU monitoring
- report IV site pain
Dopamine
- Dose-dependent DA, β1, then α1 effects
Norepinephrine
- Potent α1 vasoconstriction + some β1
Dopamine
- Shock with bradycardia
- symptomatic ↓HR
Norepinephrine
- ★First-line for septic shock
Dopamine
- IV infusion
- titrate by mcg/kg/min to HR & BP
Norepinephrine
- IV infusion
- titrate up/down to MAP
Dopamine
- Central line preferred (extravasation)
Norepinephrine
- Central line preferred (extravasation)
Dopamine
- Continuous BP/ECG
- monitor perfusion & urine output
Norepinephrine
- Continuous BP/ECG
- monitor perfusion & urine output
Dopamine
- ★Tachydysrhythmias
- Peripheral ischemia
Norepinephrine
- Reflex bradycardia
- Peripheral ischemia
Dopamine
- Extravasation can cause necrosis
- Antidote: phentolamine
Norepinephrine
- Extravasation can cause necrosis
- Antidote: phentolamine
Dopamine
- Titrate to MAP ≥ 65
Norepinephrine
- Titrate to MAP ≥ 65
Dopamine
- Continuous ICU monitoring
- report IV site pain
Norepinephrine
- Continuous ICU monitoring
- report IV site pain
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Sepsis → Norepi first; Dopamine → dose-dependent triple threat; Vasopressin → fixed-dose add-on, never solo.
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