The next pressor...

Depends on what you need it for. Usually for our vascular surgeries they like to use neo, but everything else is levo for the most part. The vaso is usually reserved for the septic patients that already are on multiple pressors.

I used to work in a general ICU, but we mostly got MICU patients (severe sepsis, GI bleeds, ARDS). We almost always used levo, then vaso, then neo. Sometimes we would use dopamine if the patient was brady or if we needed a pressor fast because we stocked dopamine on the unit. We would use neo rarely if a patient was having a lot of PVCs or arrythmias. But for sepsis, we almost always used levo until we got to 20 mcgs, and then we added vaso at 0.3 units. If the patient was still hypotensive, we would add neo, usually up to about 300 mcgs. We would also use dopamine and dobutamine up to 20 mcgs. Rarely we would use epical also.

Sepsis usually Levo, Neo, Vaso. Sometimes dopa before vaso if ARF.

Any other volume depletion/surgical- Neo, levo, vaso....

Heart related (e.g., MI, end-stage CHF) dobuatmine or dopa.

At most I've seen 5 pressors- neo, lev, vaso, dopa, epi- s/p code. Can't recall etiology.

It's always interesting to hear other teams strategies, sometimes other units even.We (neuro) titrate Levo 0-30mcgs/min as listed per rph, micu titrates only to 20mcgs/min. We use vaso @0.04 and neo to 300.

I work primarily in the SICU at my hospital and for trauma/surgery patients we usually start Levophed, then Vasopressin, and then Epi infusion. this is as far as we go

as well, i've gotten overflow pt's from other units and this is how it goes

MI: Dopamine, Levo, Epi

Neuro: Neo, levo, epi/vaso

CI: dopamine/dobutamine(arguably a pressor), then it depends on the physician.

I work in a neuroICU at a large teaching hospital, but are the primary mICU overflow and we get alot of them. In neuro, we use neo first and Levo 2nd, vaso is third if need be. mICU seems to do Levo and vaso, and than add neo. What's your teams strategy?

Depends on the situation, but we tend to go levo (30mcgs), neo (180mcgs), then vaso, dopa, and then epi.

MICU: Levo, Vaso, and then inotripics dobutamine for hearts dopamine for sepsis. Ionitropes selection may also be influenced by extent of AKI.

Levo is a great first line pressor fora septic patient who has already been volume resuccitated. It worksby vaso constricting the extremeties to adequately profuse coreorgans. The problem with neo is a) it is a weak pressor (nice forpushing in the OR if the patient gets too much prop!) and b) it worksin the same way as levophed, so many intensivists don't use it as asecond pressor because it really doesn't make sense. If 20 or 30 oflevo doesn't work, than adding neo probably won't help. Vaso is agood second-line pressor for sepsis. After that, you're desperateanyway, so neo won't hurt. I don't think I've seen anyone survive whohas needed more than three pressors. No wait, there was one!

Levo is a great first line pressor fora septic patient who has already been volume resuccitated. It worksby vaso constricting the extremeties to adequately profuse coreorgans. The problem with neo is a) it is a weak pressor (nice forpushing in the OR if the patient gets too much prop!) and b) it worksin the same way as levophed, so many intensivists don't use it as asecond pressor because it really doesn't make sense. If 20 or 30 oflevo doesn't work, than adding neo probably won't help. Vaso is agood second-line pressor for sepsis. After that, you're desperateanyway, so neo won't hurt. I don't think I've seen anyone survive whohas needed more than three pressors. No wait, there was one!

Levo has mostly alpha adrenergic activity with some beta adrenergic activity. Neo has exclusive alpha adrenergic activity. So both pressors are not the same. On very tachycardic patients adding neo to the balance might work better than adding more levo orr starting epi. In children levo has been known to cause reflective bradycardia where neo does not.

It all depend on the type of shock you have and the situations surrounding it. I've seen cardiogenic shocks survive on 4 pressors and three intotropes and methylene blue on top of all that. There are some notorious septic shocks that have profound hypotension requiring massive amounts of vasopressors but once you make it through this acute phase some of these patients recover very well.

I agree with you that in the statistical sense adding more/different vasopressors doesn't make a difference because the majority of these patients will die. And only levo has been of scientifically proven value in terms of survival.