What is the recommended use of pressors in septic shock?

Vasopressor Management in Septic Shock

Norepinephrine is the first-choice vasopressor in septic shock, with an initial target mean arterial pressure (MAP) of 65 mmHg. 1, 2

Initial Vasopressor Selection and Administration

• Norepinephrine is recommended as the first-line vasopressor due to its superior efficacy and safety profile compared to other agents 1, 2
• Administration requires central venous access, and arterial catheter placement should be performed as soon as practical for all patients requiring vasopressors 1, 2
• The initial target MAP should be 65 mmHg in most patients with septic shock 1
• Vasopressor therapy should be initiated early rather than waiting for completion of fluid resuscitation when patients remain hypotensive despite initial fluid administration 3
• At least 30 mL/kg of IV crystalloid fluid should be given within the first 3 hours before or alongside vasopressor therapy 1, 2

Management of Refractory Hypotension

• If target MAP cannot be achieved with maximum doses of norepinephrine, add vasopressin (up to 0.03 U/min) to either raise MAP or decrease norepinephrine dosage 1, 2
• The recommended starting dose of vasopressin in septic shock is 0.01-0.03 units/minute 4, 5
• Higher doses of vasopressin (above 0.03-0.04 units/minute) should be reserved for rescue therapy when other vasopressors have failed 4
• Epinephrine can be added as an alternative second agent when norepinephrine and vasopressin are insufficient 1, 6
• For epinephrine, the suggested dosing range is 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve desired MAP 6

Special Considerations

• In patients with chronic hypertension, consider a higher MAP target of 80-85 mmHg, as this may reduce the need for renal replacement therapy, though it carries an increased risk of arrhythmias 1, 7
• Dopamine should only be used as an alternative to norepinephrine in highly selected patients with low risk of tachyarrhythmias or with bradycardia 1, 2
• Low-dose dopamine should not be used for renal protection (strong recommendation) 1, 2
• Phenylephrine is not recommended except in specific circumstances such as when norepinephrine causes serious arrhythmias or when cardiac output is high but blood pressure remains low 1, 2
• Dobutamine (up to 20 μg/kg/min) should be considered in patients with persistent hypoperfusion despite adequate fluid loading and vasopressor therapy 1, 8

Monitoring and Titration

• Dynamic rather than static variables should be used to predict fluid responsiveness when available 1
• After target blood pressure has been maintained for 8 hours without catecholamines, taper vasopressin by 0.005 units/minute every hour as tolerated 5
• For epinephrine, after hemodynamic stabilization, wean incrementally over time by decreasing doses every 30 minutes over a 12-24 hour period 6
• Continuous arterial blood pressure monitoring is essential for patients receiving vasopressors 2, 9
• Consider measuring cardiac output when using pure vasopressors like vasopressin to ensure maintenance of adequate tissue perfusion 4, 8

Pitfalls and Caveats

• Delaying vasopressor initiation until complete fluid resuscitation may worsen outcomes; early administration of norepinephrine may achieve target MAP faster and reduce risk of fluid overload 9, 3
• MAP alone should not be used as the sole surrogate of organ perfusion, especially when intracranial, intra-abdominal, or tissue pressures may be elevated 7
• Vasopressin should not be used as the initial single vasopressor for septic shock 2, 4
• Excessive fluid administration before initiating vasopressors may contribute to tissue edema and organ dysfunction 10, 3