What medication is used for Tag 283?

Medication for Septic Shock: Norepinephrine is First-Line Vasopressor

Norepinephrine is the first-line vasopressor medication for septic shock (Tag 283). 1

Evidence-Based Rationale

The 2017 Surviving Sepsis Campaign guidelines provide clear recommendations for vasopressor therapy in septic shock:

1. Norepinephrine is strongly recommended as the first-choice vasopressor (strong recommendation, moderate quality of evidence) 1

2. Initial fluid resuscitation should be with crystalloids, with a minimum of 30 mL/kg (a portion may be albumin equivalent) 1

3. Vasopressor therapy should initially target a mean arterial pressure (MAP) of 65 mm Hg 1

Stepwise Approach to Vasopressor Management in Septic Shock

First-Line Therapy

• Begin norepinephrine as the first vasopressor when fluid resuscitation is insufficient to maintain target MAP
• Administer through central venous access when possible
• Titrate to maintain MAP ≥ 65 mm Hg

Second-Line Options (if norepinephrine insufficient)

• Add vasopressin (up to 0.03 U/min) to either:
  • Raise MAP to target, OR
  • Decrease norepinephrine dosage 1
• Alternatively, add epinephrine to maintain adequate blood pressure 1

Third-Line Option

• Dopamine may be used as an alternative vasopressor to norepinephrine only in highly selected patients:
  • Those with low risk of tachyarrhythmias
  • Patients with absolute or relative bradycardia 1

Important Cautions and Contraindications

• Low-dose dopamine is not recommended for renal protection (strong recommendation, high quality evidence) 1
• Phenylephrine is not recommended except in specific circumstances:
  • When norepinephrine is associated with serious arrhythmias
  • When cardiac output is known to be high and blood pressure persistently low

Fluid Therapy Considerations

Before and alongside vasopressor therapy, appropriate fluid resuscitation is essential:

• Use crystalloids as first choice for initial resuscitation and subsequent volume replacement 1
• Consider adding albumin when patients require substantial amounts of crystalloids 1
• Avoid hydroxyethyl starches for intravascular volume replacement (strong recommendation, high quality evidence) 1
• Use a fluid challenge technique where administration continues as long as hemodynamic factors improve 1

Monitoring Response

• Continuously assess hemodynamic response to vasopressor therapy
• Monitor for adverse effects including:
  • Tachyarrhythmias
  • Tissue hypoperfusion
  • Cardiac ischemia
• Adjust vasopressor doses based on ongoing assessment of MAP and tissue perfusion

By following this evidence-based approach to vasopressor therapy in septic shock, with norepinephrine as the first-line agent, clinicians can optimize outcomes for patients with this life-threatening condition.