ICU Map

Vasopressor & Inotrope Initiation & Titration

From first-line norepinephrine titration to multi-agent vasopressor escalation and inotrope selection.

RecognizeAssessDecideDifferentialInterveneReassess
Vasodilatory Shock / Refractory Hypotension (MAP < 65)
Clinical ActionInitiate Norepinephrine as first-line vasopressorExplore Topic
Start norepinephrine promptly at an institution-appropriate dose and titrate rapidly to the patient-specific MAP target (usually around 65 mmHg initially in septic shock). Exact starting doses and titration increments vary by concentration, route, protocol and shock severity.
Decision PointIs the norepinephrine requirement escalating or becoming moderate-to-high?
SSC 2026 suggests adding vasopressin when norepinephrine requirements are escalating; it does not require one universal norepinephrine cutoff. Reassess volume status, cardiac function and shock phenotype at the same time.
Differential Branches (2)
1Branch
Clinical ActionAdd vasopressin per local septic-shock protocol when norepinephrine is escalating
V1a-mediated vasoconstriction can reduce catecholamine requirements. Common ICU protocols use a low fixed-dose infusion (often 0.03 U/min, sometimes 0.04 U/min), but follow the local formulation/protocol and monitor for ischemia.
Decision PointPerform bedside Echocardiography to evaluate cardiac output & LV/RV functionExplore Topic
Differentiate persistent pure vasoplegia from myocardial depression / septic cardiomyopathy.
Clinical ActionMyocardial Dysfunction Present: Add Dobutamine (2.5–10 mcg/kg/min)
Inodilator targeting improved cardiac output and stroke volume. Monitor for tachycardia and arrhythmia.
Clinical ActionRefractory Vasoplegia: Add Epinephrine & IV Hydrocortisone (200 mg/day)
Epinephrine (0.05–0.2 mcg/kg/min) provides potent alpha-1/beta-1 support. Stress-dose steroids restore vascular responsiveness.
2Branch
Reassessment / LoopMAP/perfusion adequate on norepinephrine alone
Maintain MAP target, monitor perfusion parameters (lactate, urine output, CRT), and begin stepwise weaning as vasoplegia resolves.

An educational representation of clinical reasoning, not a diagnostic algorithm or personalized medical advice — always apply clinical judgment and institutional protocols.

Caution

Escalate — Red Flags & Critical Warnings

  • Severe peripheral cyanosis or digital ischemia on high-dose vasopressors — evaluate for hypovolemia or cardiogenic collapse requiring cardiac output support rather than pure vasoconstriction.
  • New rapid atrial fibrillation or ventricular ectopy during vasopressor escalation — consider changing to vasopressin/phenylephrine and addressing electrolyte/ischemic triggers.

Related Bedside Clinical Problems (24)

Bedside Presentations
Sudden Hypoxemia

Bedside triage of acute desaturation: signal verification, immediate danger screening (DOPE / tension pneumothorax), oxygen escalation ladder, and mechanism-based differential.

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Sudden Ventilator Deterioration & High Airway Pressures

Algorithmic troubleshooting of acute patient-ventilator collapse: the DOPE framework, peak vs plateau pressure differentiation, auto-PEEP evaluation, and manual bagging separation.

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Acute Hypotension & Undifferentiated Shock

Rapid bedside hemodynamic categorization: confirming MAP < 65 mmHg, assessing peripheral perfusion, POCUS cardiac/IVC profiling, and differentiating hypovolemic, distributive, cardiogenic, and obstructive etiologies.

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Linked Deep-Dive Topics (11)

Reference Knowledge
Shock: Foundational Critical Care Frameworkcardiovascular

Cellular dysoxia, DO2/VO2 physiology, the 4 shock phenotypes, dynamic fluid responsiveness (PLR/PPV) vs fluid tolerance (VExUS), and vasoactive pharmacology.

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Septic Shockcardiovascular

The subset of sepsis with profound circulatory and cellular/metabolic abnormality — clinically identified by a vasopressor requirement to maintain MAP ≥ 65 mmHg plus lactate > 2 mmol/L despite adequate fluid resuscitation.

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Cardiogenic Shockcardiovascular

Primary pump failure, SCAI staging (A–E), PAC hemodynamics (CPO, PAPi), inotrope selection, emergent revascularization, and mechanical circulatory support.

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Acute Right Ventricular Failurecardiovascular

RV anatomy and ischemia spiral, ventricular interdependence (D-sign), echocardiographic metrics (TAPSE, S', PAPi, VExUS), and the 4-pillar resuscitation strategy.

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Obstructive Shockcardiovascular

Extracardiac mechanical barriers to filling or ejection: Massive PE, Cardiac Tamponade, Tension Pneumothorax, and Auto-PEEP.

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Pulmonary Hypertension & Acute Decompensationcardiovascular

Hemodynamic classification, right ventricular afterload reduction, selective pulmonary vasodilation, and pulmonary hypertensive crisis management.

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Hypertensive Emergenciescardiovascular

Target organ damage assessment, intravenous antihypertensive titration, and emergency-specific blood pressure targets.

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Acute Heart Failure & Cardiogenic Congestioncardiovascular

Hemodynamic phenotypes (SCAPE vs ADHF vs Cardiogenic Shock), non-invasive positive pressure ventilation, high-dose vasodilator algorithms, loop diuretics, and sequential nephron blockade.

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Acute Aortic Syndromescardiovascular

Emergency classification, anti-impulse medical stabilization, and surgical vs endovascular management of aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer.

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Arrhythmias in Critical Illnesscardiovascular

Algorithmic tachy- and bradyarrhythmia management, new-onset ICU atrial fibrillation, wide-complex tachycardia differentiation, and refractory Torsades overdrive pacing protocols.

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Acute Mesenteric Ischemia (AMI)gi-hepatic

Rapid biphasic CTA diagnosis, mechanism-specific revascularization (embolism vs thrombosis vs venous thrombosis vs NOMI), individualized therapeutic anticoagulation, and selective second-look laparotomy.

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