Vasopressors and inotropic agents used in the operating room: Adult dosing^*¶

Drug	Functional class (predominant receptor or mechanism of action)	Bolus dose	Infusion dose	Comments
Ephedrine	Inotrope/chronotrope/vasopressor (alpha₁-adrenergic receptor agonist; beta₁- and beta₂-adrenergic receptor agonist)	5 to 10 mg boluses	N/A	Tachyphylaxis may occur with multiple repeated doses due to indirect postsynaptic release of norepinephrine Cardiovascular effects attenuated by drugs that block ephedrine uptake into adrenergic nerves (eg, cocaine) or those that deplete norepinephrine reserves (eg, reserpine) Administered with extreme caution (eg, in small incremental doses of 2.5 mg) to patients using monoamine oxidase (MAO) inhibitors or methamphetamines since exaggerated hypertensive responses or life-threatening dysrhythmias may occur
Phenylephrine	Vasopressor (alpha₁-adrenergic receptor agonist)	50 to 100 mcg boluses (may begin infusion if repeated bolus doses are necessary)	10 to 100 mcg/minute or 0.1 to 1 mcg/kg/minute	Often selected to treat hypotension if normal or elevated HR is present Genetic polymorphisms lead to variable individual responses
Norepinephrine	Inotrope/vasopressor (alpha₁- and beta₁-adrenergic receptor agonist)	4 to 8 mcg (may begin infusion if repeated bolus doses are necessary)	1 to 20 mcg/minute or 0.01 to 0.3 mcg/kg/minute	Often selected as a first-line agent during noncardiac surgery, particularly for treatment of most types of shock Norepinephrine 8 mcg is approximately equivalent in potency to phenylephrine 100 mcg Peripheral extravasation of a high concentration may cause tissue damage
Epinephrine	Inotrope/chronotrope/vasopressor (alpha₁-adrenergic receptor agonist; beta₁- and beta₂-adrenergic receptor agonist)	4 to 10 mcg initially; up to 100 mcg boluses may be used when initial response is inadequate	1 to 100 mcg/minute or 0.01 to 1 mcg/kg/minute Note changing effects across dose range: Low doses have primarily beta₂-adrenergic effects at 1 to 2 mcg/minute or 0.01 to 0.02 mcg/kg/minute Intermediate doses have primarily beta₁- and beta₂-adrenergic effects at 2 to 10 mcg/minute or 0.02 to 0.1 mcg/kg/minute High doses have primarily alpha₁-adrenergic effects at 10 to 100 mcg/minute or 0.1 to 1 mcg/kg/minute	First-line treatment for cardiac arrest and for anaphylaxis May be administered IV, IM, or via an endotracheal tube in emergencies Low doses cause bronchodilatory effects and may cause arterial vasodilation and decreased BP Intermediate doses cause increases in HR and BP High doses cause vasoconstriction, with possible severe hypertension and adverse metabolic effects Individual responses to dose-related effect are variable
Vasopressin	Vasopressor (vasopressin₁ and vasopressin₂ receptor agonist)	1 to 4 units	0.01 to 0.04 units/minute Doses >0.04 units/minute up to 0.1 units/minute are reserved for salvage therapy (ie, failure to achieve adequate BP goals with other vasopressor agents)^¶	Effective for treatment of hypotension refractory to administration of catecholamines or sympathomimetics such as ephedrine, phenylephrine, or norepinephrine No direct effect on HR Little effect on PVR; can cause splanchnic vasoconstriction Individual responses to dose-related effects are variable Peripheral extravasation may cause skin necrosis
Dopamine	Inotrope/vasopressor/dose-dependent chronotropy (dopaminergic, beta₁-, beta₂-, and alpha₁-adrenergic receptor agonist)	N/A	2 to 20 mcg/kg/minute Note changing effects across dose range: Low doses have primarily dopaminergic effects at <3 mcg/kg/minute Intermediate doses have primarily beta₁- and beta₂-adrenergic effects at 3 to 10 mcg/kg/minute High doses have primarily alpha₁-adrenergic effects >10 mcg/kg/minute	Low doses may exacerbate hypotension via beta₂ stimulation High doses may cause vasoconstriction, adverse metabolic effects, and arrhythmias
Dobutamine	Inotrope/vasodilator/dose-dependent chronotropy (beta₁- and beta₂-adrenergic receptor agonist)	N/A	1 to 20 mcg/kg/minute	Exacerbation of hypotension is possible due to dose-dependent vasodilation (via beta₂ stimulation); concurrent administration of a potent vasoconstrictor such as norepinephrine or vasopressin may be necessary
Milrinone	Inotrope/vasodilator (phosphodiesterase inhibitor) (decreases rate of cyclic adenosine monophosphate [cAMP] degradation)	N/A	0.375 to 0.75 mcg/kg/minute (a loading dose of 50 mcg/kg over ≥10 minutes may be administered, but may be omitted to avoid hypotension)	Exacerbation of hypotension is likely due to vasodilation (via phosphodiesterase inhibition); concurrent administration of a potent vasoconstrictor such as norepinephrine or vasopressin may be necessary
Isoproterenol	Inotrope/chronotrope/vasodilator (beta₁- and beta₂-adrenergic receptor agonist)	N/A	5 to 20 mcg/minute or 0.05 to 0.2 mcg/kg/minute	Exacerbation of hypotension is likely due to dose-dependent vasodilation (via beta₂ stimulation) May cause arrhythmias Not available in most settings
Levosimendan	Inotrope/vasodilator(calcium sensitizer; phosphodiesterase inhibition)	N/A	Initial dose: 6 to 12 mcg/kg infused over 10 minutes. Maintenance dose: 0.05 to 0.2 mcg/kg/minute by continuous infusion	Short-term effects include dose-dependent reduction in cardiac filling pressures, increase in cardiac index, and vasodilation May have favorable effects on relaxation properties in failing hearts Not available in the United States

BP: blood pressure; HR: heart rate; IM: intramuscular; IV: intravenous; N/A: not applicable; PVR: pulmonary vascular resistance.

* Dose ranges are based on adult patients of average size.

¶ Refer to related UpToDate content on hemodynamic management during anesthesia and surgery.

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Vasopressors and inotropic agents used in the operating room: Adult dosing*¶

Vasopressors and inotropic agents used in the operating room: Adult dosing^*¶