What is the target blood pressure for a septic shock patient on norepinephrine (noradrenaline) infusion?

Target Blood Pressure in Septic Shock Patients on Norepinephrine Infusion

The target mean arterial pressure (MAP) for patients with septic shock on norepinephrine infusion should be 65 mmHg, with individualization to higher targets (75-85 mmHg) for patients with chronic hypertension. 1, 2

Initial MAP Target and Rationale

• The Surviving Sepsis Campaign guidelines strongly recommend norepinephrine as the first-choice vasopressor with an initial target MAP of 65 mmHg 1, 2
• This recommendation is based on moderate quality evidence showing that targeting a MAP of 65 mmHg provides adequate tissue perfusion while minimizing vasopressor exposure 1, 2
• A multicenter trial comparing MAP targets of 65 mmHg versus 85 mmHg found no significant difference in 28-day mortality (36.6% in high-target group vs. 34.0% in low-target group) 1
• Targeting higher MAPs (>65 mmHg) is associated with increased risk of cardiac arrhythmias without improving overall survival 1, 3

Special Populations Requiring Higher MAP Targets

• For patients with chronic hypertension, a higher MAP target of 75-85 mmHg is recommended 1, 2
• Evidence shows that patients with pre-existing hypertension have reduced need for renal replacement therapy when maintained at higher MAP targets 1, 4
• In elderly patients (>75 years), a lower MAP target (60-65 mmHg) may be beneficial, as suggested by a pilot trial showing reduced mortality compared to higher targets (75-80 mmHg) 1

Monitoring and Titration Approach

• Use continuous arterial blood pressure monitoring via arterial catheter for all patients on vasopressors 1, 2
• Titrate norepinephrine dose to achieve the target MAP, starting with the goal of 65 mmHg 2, 5
• Adjust MAP alarms to match the prescribed target range, which can significantly improve the percentage of time spent within target (75% vs. 49% when using standard alarms) 5
• Supplement MAP monitoring with assessment of tissue perfusion markers: 1, 4
  • Serum lactate levels
  • Urine output
  • Mental status
  • Skin perfusion

Management of Refractory Hypotension

• If unable to achieve target MAP with maximum doses of norepinephrine, consider adding vasopressin (up to 0.03 units/minute) 1, 2
• Vasopressin should not be used as the single initial vasopressor, and doses higher than 0.03-0.04 units/minute should be reserved for salvage therapy 1, 2
• Epinephrine can be added to or substituted for norepinephrine when an additional agent is needed to maintain adequate blood pressure 1
• Dopamine should only be used as an alternative to norepinephrine in highly selected patients with low risk of tachyarrhythmias or relative bradycardia 1, 2

Important Caveats and Considerations

• MAP alone is not a perfect surrogate for organ perfusion, especially when intracranial, intra-abdominal, or tissue pressures may be elevated 4
• Recent evidence suggests that if reaching a higher MAP requires high norepinephrine doses or does not resolve mottled skin at 24 hours, it may be associated with increased mortality 6
• Ensure adequate fluid resuscitation before or alongside vasopressor therapy 1, 2
• Phenylephrine is not recommended except in specific circumstances (e.g., when norepinephrine causes serious arrhythmias) 1, 2
• Avoid using low-dose dopamine for renal protection, as this practice is not supported by evidence 1, 2