Sepsis Vasopressor Selection

Start norepinephrine when MAP remains below approximately 60 to 65 mm Hg after initial fluid resuscitation, or earlier when ongoing hypotension is causing impaired perfusion. Expert consensus supports not delaying vasopressor therapy until fluids are complete; the operational initial target is MAP at least 65 mm Hg. ScienceDirect+1ScienceDirectCurrent use of vasopressors in septic shockPubMedInotropes and Vasopressors - StatPearls - NCBI Bookshelf - NIH

Norepinephrine is the preferred initial vasopressor in adult septic shock. The Surviving Sepsis Campaign makes a strong recommendation for norepinephrine over dopamine, vasopressin, epinephrine, selepressin, and angiotensin II as first-line therapy. Its predominantly peripheral vasoconstrictor effect with modest inotropy makes it suitable for most vasodilatory shock states. PubMed+1PubMedSurviving sepsis campaign: international guidelines for ... - PMCjaccMixed Cardiogenic-Vasodilatory Shock: Current Insights and Future Directions

Escalate therapy according to MAP and evidence of perfusion, not MAP alone. Follow mental status, urine output, skin temperature and capillary refill, serial lactate, and the trajectory of vasopressor requirement. An elevated lactate may represent impaired oxygen delivery, but adrenergic stimulation—including administered epinephrine—can increase lactate production without global hypoperfusion. jacc+1jaccMacrovascular Hemodynamics and Peripheral Perfusion in Cardiogenic Shock: Exploring Current Targets and Future DirectionsPubMedThe Surviving Sepsis Campaign: Fluid Resuscitation and Vasopressor Therapy Research Priorities in Adult Patients

Add vasopressin to norepinephrine for persistent hypotension during dose escalation. The Surviving Sepsis Campaign suggests adding vasopressin rather than further escalating norepinephrine, and contemporary guidance describes a fixed infusion of 0.03 U/min, commonly considered when norepinephrine approaches 0.25 µg/kg/min. PubMed+1PubMedSurviving sepsis campaign: international guidelines for ... - PMCPubMedCurrent and future strategies aiming at reducing catecholamine exposure in septic shock

Vasopressin is an adjunct, not routine first-line monotherapy. In VASST, low-dose vasopressin added to norepinephrine did not improve overall mortality or adverse events versus norepinephrine alone, although a less-severe sepsis subgroup had lower mortality. It can reduce norepinephrine requirements and may increase urine output, but neither response establishes renal recovery or adequate global perfusion. ScienceDirectScienceDirectVasopressin Blood Level - an overview | ScienceDirect Topics

Use epinephrine as an additional vasopressor when MAP remains inadequate despite norepinephrine, with or without vasopressin. It raises MAP but lacks demonstrated mortality benefit and may cause tachyarrhythmia and adrenergic hyperlactatemia; therefore, interpret a lactate increase after epinephrine initiation in the context of peripheral perfusion and other hemodynamic markers. PubMed+1PubMedThe Surviving Sepsis Campaign: Fluid Resuscitation and Vasopressor Therapy Research Priorities in Adult PatientsPubMedCurrent and future strategies aiming at reducing catecholamine exposure in septic shock

Consider angiotensin II only in refractory vasodilatory shock after norepinephrine-based therapy and usually after vasopressin. In ATHOS-3, angiotensin II increased MAP without increasing norepinephrine in 70% of patients with vasodilatory shock, most of whom had septic shock and were receiving norepinephrine greater than 0.2 µg/kg/min for more than 6 hours; the trial did not demonstrate a 28-day mortality benefit. PubMedPubMedVasopressin and its analogues in patients with septic shock: holy Grail or unfulfilled promise?

Do not use a fixed norepinephrine dose or elapsed shock duration as the sole determinant for vasopressin timing or further escalation. Vasopressor responsiveness must be interpreted with cardiac output, ventricular function, fluid tolerance, source control, and evidence of organ perfusion. PubMed+1PubMedVasopressin and its analogues in patients with septic shock: holy Grail or unfulfilled promise?jaccMixed Cardiogenic-Vasodilatory Shock: Current Insights and Future Directions

An unexpectedly poor pressor response should prompt a focused search for a nonvasoplegic component. Obtain bedside echocardiography when low-output or right-ventricular failure is plausible, and urgently identify reversible obstructive or hemorrhagic causes. In a low-output syndrome, angiotensin II is contraindicated; continued pure afterload augmentation can impair forward flow even if MAP rises. jacc+1jaccMixed Cardiogenic-Vasodilatory Shock: Current Insights and Future DirectionsPubMedRefractory Shock - StatPearls - NCBI Bookshelf

Monitor response at the bedside with MAP, serial vasopressor dose, capillary refill and extremity perfusion, urine output, mentation, and lactate trend. Lactate is prognostically useful but biologically nonspecific in shock: reduced cardiac output and global hypoperfusion cause type A elevation, whereas endogenous or exogenous adrenergic stimulation can produce type B elevation. jaccjaccMacrovascular Hemodynamics and Peripheral Perfusion in Cardiogenic Shock: Exploring Current Targets and Future Directions

Avoid interpreting an epinephrine-associated lactate increase as automatic evidence of worsening shock. A discordant pattern—improving capillary refill, MAP, urine output, and clinical perfusion with rising lactate after epinephrine—should lead to reassessment of adrenergic lactate generation rather than uncritical escalation of vasopressors. jacc+1jaccMacrovascular Hemodynamics and Peripheral Perfusion in Cardiogenic Shock: Exploring Current Targets and Future DirectionsPubMedThe Surviving Sepsis Campaign: Fluid Resuscitation and Vasopressor Therapy Research Priorities in Adult Patients

Actively surveil for tachyarrhythmia with catecholamines, especially dopamine and epinephrine. The norepinephrine-versus-dopamine evidence base shows lower mortality with norepinephrine (risk ratio 0.89, 95% CI 0.81-0.98) and fewer arrhythmias (risk ratio 0.48, 95% CI 0.40-0.58). PubMedPubMedThe Surviving Sepsis Campaign: Fluid Resuscitation and Vasopressor Therapy Research Priorities in Adult Patients

Once MAP and perfusion stabilize, down-titrate vasopressors while continuing to reassess the underlying shock driver. A decline in dose requirement is favorable only when accompanied by sustained pressure and perfusion; do not accept a lower dose at the cost of recurrent hypotension or deteriorating end-organ function. ScienceDirect+1ScienceDirectCurrent use of vasopressors in septic shockPubMedRefractory Shock - StatPearls - NCBI Bookshelf