Initial Vasopressor Management in Septic Shock
Start norepinephrine as your first-line vasopressor, targeting a mean arterial pressure (MAP) of 65 mmHg. 1, 2, 3
Which Vasopressor to Start
Norepinephrine is the only appropriate first-choice vasopressor for septic shock, with strong evidence showing superior mortality outcomes and fewer arrhythmias compared to dopamine. 1
Dopamine should be avoided except in highly selected patients with absolute or relative bradycardia and low risk of tachyarrhythmias—this is a rare exception, not routine practice. 1, 2
Never start with vasopressin alone—it must only be added to norepinephrine, never used as initial monotherapy. 1, 2
Starting Dose and Administration
Begin norepinephrine at 0.05 mcg/kg/min and titrate upward in increments of 0.05-0.2 mcg/kg/min every 10-15 minutes to achieve MAP ≥65 mmHg. 4
Norepinephrine requires central venous access for safe administration. 2, 3
Place an arterial catheter as soon as practical for continuous blood pressure monitoring—this is essential, not optional. 1, 2
Timing Considerations
Start norepinephrine early in patients with profound hypotension (diastolic BP ≤40 mmHg or diastolic shock index ≥3), even while simultaneously administering fluid resuscitation—do not delay vasopressors waiting to complete fluid boluses in severely hypotensive patients. 5, 6
Early norepinephrine administration (within the first hour) increases cardiac output, improves microcirculation, prevents fluid overload, and achieves shock control faster than delayed administration. 6, 7, 8
The CENSER trial demonstrated that early norepinephrine significantly increased shock control by 6 hours (76% vs 48%) and reduced cardiogenic pulmonary edema and arrhythmias. 7
Fluid Resuscitation Context
Administer at least 30 mL/kg IV crystalloid within the first 3 hours, but do not withhold norepinephrine in profoundly hypotensive patients waiting to complete this volume. 1, 3
Adequate fluid resuscitation should ideally precede vasopressors, but using vasopressors early as an emergency measure is necessary when diastolic blood pressure is critically low. 1
When to Add Second-Line Agents
Add vasopressin 0.03 units/min (not 0.01-0.03, use the full 0.03 units/min) when norepinephrine requirements exceed 0.25-0.5 mcg/kg/min to either raise MAP to target or decrease norepinephrine dosage. 1, 2, 9
Alternatively, add epinephrine as a second agent when additional vasopressor support is needed beyond norepinephrine alone. 1
For persistent hypoperfusion despite adequate MAP and vasopressor support, add dobutamine up to 20 mcg/kg/min rather than escalating vasopressors further. 1
Critical Pitfalls to Avoid
Never use low-dose dopamine for renal protection—this is strongly contraindicated and provides no benefit while increasing arrhythmia risk. 1, 2, 10
Do not use phenylephrine as first-line therapy—it may raise blood pressure on the monitor while actually worsening tissue perfusion through excessive vasoconstriction without cardiac support. 1, 2
Avoid delaying norepinephrine in severely hypotensive patients (MAP <50 mmHg or diastolic BP ≤40 mmHg)—prolonged profound hypotension independently increases mortality. 5, 6
Do not increase vasopressin beyond 0.03-0.04 units/min except as salvage therapy when all other options have failed. 1, 2
MAP Target Adjustments
Target MAP of 65 mmHg is appropriate for most patients, but consider higher targets (80-85 mmHg) in patients with chronic hypertension, as this may reduce need for renal replacement therapy despite increased arrhythmia risk. 1, 3
Supplement blood pressure targets with assessment of end-organ perfusion: lactate clearance, urine output, mental status, and skin perfusion. 1