Episode 19: Vasoactive medications

In this episode I review the receptors that vasoactive drugs act on.  I then review the main vasoactive medications used in the OR and the ICU to treat acute hypotension and the ones used to treat acute hypertension.

15 Replies to “Episode 19: Vasoactive medications”

  1. Hi Dr. Wolpaw,

    I found your podcast through Twitter, and have found it incredibly helpful as supplemental content for a critical care rotation I recently completed, and as preparation for an upcoming anesthesiology elective. Thanks for investing the time to create this podcast series!

  2. Hey Dr. Wolpaw!

    would you be able to comment on the use of midodrine in the ICU, both in it’s pharmacology/efficacy when compared to other alpha agonists, as well as the relatively recent evidence on its use in resolving septic shock? Thanks!!

    1. Hi Kia,

      Great question. Midodrine, as you know, is an oral alpha-1 agonist, essentially an oral version of phenylephrine. It has traditionally been shown to be used in autonomic dysfunction and hepatorenal syndrome but has recnetly, as you mention, been looked at for patients weaning off pressors in the ICU. Anecdotally we definitely use this approach regularly here at Hopkins with patients who are otherwise doing well but still requiring low doses of vasopressors (usually either levophed or phenylephrine). We start at 15mg q8h and increase to a max of 30mg q8h. In renal impairment we may space this out to q12h. There is not a lot of great evidence but there are some case reports, a small prospective trial from MGH in 2013, and a larger retrospective trial in Chest by Whitson et al this past June of 2016. These all suggest a modest benefit to midodrine in terms of weaning pressors and possibly reducing ICU length of stay. There are very few side effects of note. Therefore, all told, I think it makes sense to use this medication in patients in the ICU who could go to the floor except for a residual pressor requirement.

      If anyone out there has a different experience with midodrine let us know. Thanks for the question Kia.

      Best,
      Jed

  3. Hey Dr. Walpaw,

    Thanks so much for your podcast, its a great addition to any study plan and always gets me thinking. Just a quick question regarding this episode – at around 19:00 minutes you start talking about Dobutamine, but then switch to talking about Dopamine. I think the section was intended to be entirely about Dopamine as you discussed renal dosing, but just wondering if you could clarify?

    Also down here in Australia we tend to use a lot of Metaraminol (Aramine), often in place of Phenylephrine. Do you tend to use it much stateside – and if so what do you feel are the pros and cons of using either?

    Thanks so much!

    1. Hi Mike,

      Great catch, thanks for pointing that out. Yes, I meant to say Dopamine for that entire section.

      I have never used Aramine or seen it used so unfortunately I can’t comment on how it compares to phenylephrine. I don’t believe it’s used much here in the US.

      Thanks for listening and for all you do out there every day!

      Best,
      Jed

  4. Dr. Wolpaw,

    Thanks for the great review of vasoactive medications! Just curious if you have any plans to do a cardiac follow up episode on cardiac anesthesia (CABGs, valve replacements, TAVR, etc.)?

    Thanks again!

    1. Hi Craig,

      I am actually meeting with one of our cardiac anesthesiologists this week to record an episode on the basics of cardiac anesthesia so stay tuned for that. Thanks for listening!

      Best,
      Jed

  5. Hi!
    Thanks for this great podcast!
    In it you mentorn that vassopressin is a drug that raise systemic vascular resistance BUT NOT the pulmonary pressure.. any articles or references that has concluded this that you can point to?
    Abdi Anesthesia resident Sweden

  6. Dr Wolpaw-

    I recently discovered your podcasts and think they are great. Thank you for the great review of many anesthesia and critical care comments. I noticed you did not mention the effects on milrilnone on pulmonary vasculature. One of the drugs nice benefits can be that it decreases PVR which can be helpful in patients with pulmonary hypertension, correct?

    1. Hi Crystal,

      You are correct. Milrinone does have the ability to decrease pulmonary vascular resistance and also to increase right heart contractility, both of which can be very beneficial in patients with pulmonary hypertension and/or poor right heart function.

      Best,
      Jed

  7. please i need the power point presentation or slides of this episode Episode 19: Vasoactive medications
    to follow the lecture easily please

      1. please i need the slides with each episode please there are a lot of episodes without slides and i have a more difficulty in listening to episodes without slides because of the language and i am from egypt so there are a lot of words are missing when i hear the episodes

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