From the Guidelines
Vasopressors should be initiated in septic patients when fluid resuscitation fails to restore adequate blood pressure and tissue perfusion, or immediately if the patient presents with septic shock, with norepinephrine as the first-line vasopressor of choice, targeting a mean arterial pressure (MAP) of at least 65 mmHg. The decision to start vasopressors is guided by the principles of early goal-directed therapy, which aims to restore adequate blood pressure and tissue perfusion to prevent organ dysfunction and improve outcomes 1.
Key Considerations for Vasopressor Initiation
- Fluid resuscitation with at least 30 mL/kg of crystalloids should be attempted first to restore adequate blood pressure and tissue perfusion 2, 3.
- Norepinephrine is recommended as the first-choice vasopressor due to its effectiveness in maintaining blood pressure with a lower risk of arrhythmias compared to other agents 1, 4.
- The initial target MAP should be 65 mmHg, as recommended by the Surviving Sepsis Campaign guidelines 1, 2.
Preferred Choice of Vasopressor
- Norepinephrine is the preferred initial vasopressor, started at a dose of 0.05-0.1 mcg/kg/min and titrated to maintain a MAP of at least 65 mmHg, with a maximum dose of 3.3 mcg/kg/min 1, 4.
- Vasopressin can be added as a second agent at a fixed dose of 0.03-0.04 units/min to either raise MAP to target or decrease norepinephrine dosage, but it should not be used as the initial vasopressor 1, 5.
- Epinephrine and dopamine are considered alternative agents but are not recommended as first-line due to potential side effects and lower efficacy in certain situations 1, 4, 5.
Administration and Monitoring
- Administration of vasopressors requires central venous access, though peripheral administration can be used temporarily if central access is delayed.
- Continuous monitoring of blood pressure, cardiac output, and signs of tissue perfusion is crucial to adjust vasopressor doses and avoid complications.
By following these guidelines and prioritizing the use of norepinephrine as the first-line vasopressor, clinicians can improve outcomes in septic patients by maintaining adequate blood pressure and tissue perfusion, thereby reducing morbidity, mortality, and improving quality of life.
From the FDA Drug Label
2.2 Administration In general, titrate to the lowest dose compatible with a clinically acceptable response. The recommended starting dose is: Post-cardiotomy shock: 0.03 units/minute Septic Shock: 0. 01 units/minute
- 2 Hypotension associated with Septic Shock ... the suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min, and is titrated to achieve a desired mean arterial pressure (MAP).
Initiation of Vasopressors: Vasopressors should be initiated in septic patients when they require hemodynamic support to achieve a desired mean arterial pressure (MAP). Preferred Choice of Vasopressor: The labels do not explicitly state a preferred choice between vasopressin and epinephrine. However, the labels provide dosing information for both options:
- Vasopressin: starting dose of 0.01 units/minute for septic shock
- Epinephrine: starting dose of 0.05 mcg/kg/min to 2 mcg/kg/min for septic shock-associated hypotension [6] [7]
From the Research
Initiation of Vasopressors in Septic Patients
- Vasopressors should be initiated early in septic patients, as soon as possible, to achieve a target mean arterial pressure (MAP) of ≥65 mmHg 8, 9.
- The main trigger for vasopressor use is an insufficient MAP response to initial fluid resuscitation 8.
- Early administration of vasopressors, preferably during the first hour after diagnosis of septic shock, may have a multimodal action and potential advantages, leading to lower morbidity and mortality in the management of septic patients 9.
Preferred Choice of Vasopressor
- Norepinephrine is the recommended first-line vasopressor in septic patients, targeting predominantly a MAP >60-65 mmHg 8, 10.
- Vasopressin is recommended as second-line vasopressor therapy instead of norepinephrine dose escalation in patients with septic shock and persistent arterial hypotension 11, 10.
- Epinephrine may be considered in settings where norepinephrine is unavailable or in patients with refractory septic shock and myocardial dysfunction 11, 10.