ICU Vasopressor & Hemodynamics Decision Map

Step 1 — Identify the Shock Subtype

Tap to reveal hemodynamic profile

Select the shock type that best fits your patient's presentation:

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Distributive

Septic · Anaphylactic · Neurogenic

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Cardiogenic

AMI · Severe HF · Post-cardiac surgery

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Hypovolemic

Hemorrhagic · Fluid loss

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Obstructive

PE · Tension PTX · Tamponade

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Vasodilatory

Post-bypass · Adrenal · Drug-induced

⬡ Hemodynamic Profile

Step 2 — Select Vasopressor / Inotrope

Tap for full clinical profile

Click any agent to see mechanism, dosing, indications, and cautions:

Step 3 — Complication Manager

Tap a problem for management

Tap a complication for time course, management, and switch options:

Don't Miss — Critical Safety Alerts

⚠ Mesenteric Ischemia

High-dose vasopressin or norepinephrine → splanchnic vasoconstriction. Monitor for abdominal pain, rising lactate, absent bowel sounds. Vasopressin >0.03–0.04 units/min increases risk significantly.

⚠ Extravasation Injury

All vasopressors: use central line when possible. Peripheral extravasation → phentolamine 5–10 mg in 10 mL NS locally within 12 hrs. Dopamine and norepinephrine carry highest tissue necrosis risk.

⚠ Adrenal Insufficiency Masking

Vasopressor-refractory shock: always consider relative adrenal insufficiency. Hydrocortisone 200 mg/day IV in patients not responding to fluids + vasopressors (ADRENAL, APROCCHSS). ⚠ Verify against SCCM 2024 update.

⚠ Type B Lactic Acidosis — Epinephrine

Epinephrine causes type B lactic acidosis via β2-mediated glycogenolysis — does NOT always indicate worsening tissue hypoperfusion. Contextualize with clinical picture, not lactate alone.

Step 4 — Titration Reference

Dose ranges, targets, endpoints

⚠ Before Titrating Up

Confirm: (1) adequate volume resuscitation completed, (2) MAP target defined per patient context, (3) cause of shock addressed — vasopressors treat the symptom, not the disease. MAP 65 mmHg is standard unless higher is indicated (chronic HTN, TBI, post-cardiac surgery).

Agent	Starting Dose	Usual Range	Max / Ceiling	Titration Increment	Target Endpoint
Norepinephrine	0.01–0.05 mcg/kg/min	0.1–0.5 mcg/kg/min	No hard ceiling; >1 mcg/kg/min = high dose ⚠	0.02–0.05 q5–10 min	MAP ≥65 mmHg; reassess q1h
Vasopressin	0.03 units/min (fixed)	0.01–0.04 units/min	0.04 units/min — do NOT exceed	Fixed — not typically titrated	Adjunct to NE; catecholamine-sparing
Epinephrine	0.01–0.05 mcg/kg/min	0.05–0.5 mcg/kg/min	1–2 mcg/kg/min (arrest: 1 mg IV q3–5 min)	0.02–0.05 q5 min	MAP ≥65; ROSC in arrest; anaphylaxis resolution
Phenylephrine	0.4–2 mcg/kg/min	0.5–6 mcg/kg/min	6 mcg/kg/min	0.5 q5–10 min	MAP ≥65; watch for reflex bradycardia
Dopamine	2–5 mcg/kg/min	5–15 mcg/kg/min	20 mcg/kg/min	2–5 q10 min	MAP ≥65; monitor closely for arrhythmia
Dobutamine	2–3 mcg/kg/min	5–15 mcg/kg/min	20 mcg/kg/min	1–2 q10 min	CI >2.2 L/min/m²; UO; lactate clearance

Vasopressor Weaning — When & How

✓ Criteria Before Weaning

Source of shock controlled or resolving · MAP stable ≥65 mmHg on current dose · Lactate trending down · No new vasopressor requirements in last 4–6 hrs · Fluid balance acceptable

Weaning Sequence

Wean most recently added agent first. Reduce by 25–50% of current dose every 30–60 min if MAP remains stable. Vasopressin: typically wean last or discontinue simultaneously when NE ≤0.1 mcg/kg/min. Avoid abrupt discontinuation — rebound vasodilation can precipitate re-shock. Monitor continuously for 2 hrs after final wean.

⚠ Verify vasopressin weaning sequence against current institutional protocol. Sources: VASST trial; Surviving Sepsis Campaign 2021.

Step 5 — Special Populations

Tap for tailored recommendations

Multiple populations may be relevant to your patient:

References & Evidence Base

SCCM 2021
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021.
Evans L, Rhodes A, et al. Crit Care Med. 2021;49(11):e1063–e1143. Primary source for vasopressor sequencing, MAP targets, and corticosteroid use.
VASST 2008
Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock.
Russell JA, et al. NEJM. 2008;358:877–887. Established vasopressin as adjunct; no mortality difference but vasopressor-sparing effect confirmed.
VANISH 2016
Effect of Early Vasopressin vs Norepinephrine on Kidney Failure in Patients with Septic Shock.
Gordon AC, et al. JAMA. 2016;316(5):509–518. Early vasopressin did not reduce renal failure; informed current adjunct rather than first-line positioning.
SOAP II 2010
Comparison of Dopamine and Norepinephrine in the Treatment of Shock.
De Backer D, et al. NEJM. 2010;362:779–789. Higher arrhythmia rate with dopamine; supported norepinephrine as first-line preferred agent.
ADRENAL 2018
Adjunctive Glucocorticoid Therapy in Patients with Septic Shock.
Venkatesh B, et al. NEJM. 2018;378:797–808. Hydrocortisone accelerated shock reversal but did not reduce 90-day mortality.
AHA/ACC 2022
AHA/ACC/HFSA Guideline for the Management of Heart Failure.
Heidenreich PA, et al. J Am Coll Cardiol. 2022;79(17):e263–e421. Inotrope selection and hemodynamic support in cardiogenic shock.
⚠ VERIFY
Flagged for your review:
Vasopressin dosing ceiling (0.04 units/min); hydrocortisone dosing in refractory shock; phenylephrine in AF recommendation. Please verify against your institution's current formulary and the most recent SCCM update.

Clinical Calculators

Enter patient values · Results appear instantly

All calculations are for clinical reference only — verify results and apply clinical judgment before acting.

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MAP Calculator

Mean Arterial Pressure · Target-aware interpretation

Systolic BP (SBP)

mmHg

Diastolic BP (DBP)

mmHg

Patient context

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Vasopressor Dose Converter

mcg/kg/min ↔ mL/hr · All 6 agents

Drug

Patient weight

Standard concentration

Custom concentration

mcg/mL

Convert from

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Norepinephrine Equivalents (NEE)

Vasopressor load score · Weaning & severity benchmark

Enter doses currently running. Leave blank if not in use.

Norepinephrine

mcg/kg/min

Epinephrine

mcg/kg/min

Dopamine

mcg/kg/min

Phenylephrine

mcg/kg/min

Vasopressin

units/min

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Shock Index

HR ÷ SBP · Rapid haemodynamic instability triage

Heart rate (HR)

bpm

Systolic BP (SBP)

mmHg

Clinical context

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Pulse Pressure Variation (PPV)

Fluid responsiveness · Mechanically ventilated patients

Measure PP over one respiratory cycle. Valid only in sinus rhythm, fully mechanically ventilated, Vt ≥8 mL/kg.

Maximum pulse pressure (PP_max)

mmHg

Minimum pulse pressure (PP_min)

mmHg

Limitations

Invalid in: spontaneous breaths · arrhythmia · RV failure · open chest · Vt <8 mL/kg. Use PLR as alternative in these patients.

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Lactate Clearance

SSC 2021 resuscitation endpoint · % clearance over time

Initial lactate

mmol/L

Repeat lactate

mmol/L

Time between measurements

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Cardiovascular SOFA Score

Vasopressor-specific organ failure component

Select the highest vasopressor requirement in the last 24 hrs.

MAP & vasopressor status

Creatinine / Urine output (renal)

Bilirubin (hepatic)

PaO2/FiO2 or SpO2/FiO2 (respiratory)

GCS (neurological)

Platelets (coagulation)

Calculators reference: SOFA — Vincent et al, JAMA 1996 · NEE — Auchet et al, Ann Intensive Care 2017 · PPV — Marik et al, Crit Care Med 2009 · Lactate clearance — SSC 2021 · MAP formula — standard clinical convention · Shock Index — Allgöwer & Burri 1967 · All calculations are for reference only — verify against current guidelines and institutional practice.