What is the dose of vasopressors (e.g. norepinephrine) when initiating steroids in sepsis?

Vasopressor Dosing Threshold for Steroid Initiation in Sepsis

Initiate corticosteroids (hydrocortisone 200 mg/day) when adequate fluid resuscitation and vasopressor therapy fail to restore hemodynamic stability, not at a specific vasopressor dose threshold. 1

Guideline-Based Approach to Steroid Initiation

The Surviving Sepsis Campaign explicitly recommends against using intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. 1 The decision is based on hemodynamic response, not a predetermined vasopressor dose cutoff. 1

When Steroids Are Indicated

• Refractory shock is the key criterion: steroids should only be considered when hemodynamic stability cannot be achieved despite adequate fluid resuscitation (minimum 30 mL/kg crystalloids) and vasopressor therapy. 1, 2

• The guideline does not specify an exact norepinephrine dose threshold, but the clinical context suggests considering steroids when patients remain hypotensive despite escalating vasopressor support. 1

• Hydrocortisone 200 mg per day is the recommended dose when steroids are indicated (Grade 2C recommendation). 1

Practical Implementation Algorithm

Step 1: Optimize fluid resuscitation first

• Ensure at least 30 mL/kg crystalloids have been administered in the first 3 hours. 1, 2
• Continue fluid challenge technique as long as hemodynamic improvement occurs. 1

Step 2: Initiate and escalate vasopressors

• Start norepinephrine as first-line vasopressor targeting MAP ≥65 mmHg. 1, 2
• If MAP target not achieved with norepinephrine alone, add vasopressin 0.03 units/minute before considering steroids. 1, 2
• Consider adding epinephrine as a third agent if needed. 1, 2

Step 3: Assess for steroid indication

• If hemodynamic instability persists despite the above measures, initiate hydrocortisone 200 mg/day. 1
• Do not use ACTH stimulation testing to guide this decision. 1

Steroid Tapering Strategy

• Taper hydrocortisone when vasopressors are no longer required (Grade 2D recommendation). 1
• This reinforces that steroid use is tied to vasopressor dependency, not a specific dose threshold. 1

Common Pitfalls to Avoid

• Do not initiate steroids prophylactically at a predetermined vasopressor dose (e.g., norepinephrine >0.25 mcg/kg/min) without first ensuring adequate fluid resuscitation and attempting vasopressor escalation. 1

• Do not delay vasopressor escalation while waiting to see if steroids will work—add vasopressin or epinephrine as clinically indicated. 2

• Do not use steroids as a substitute for appropriate vasopressor management; they are adjunctive therapy for refractory shock only. 1

Evidence Quality Considerations

The recommendation against routine steroid use carries a Grade 2C rating, indicating moderate-quality evidence with conditional recommendation strength. 1 This reflects that while steroids may benefit select patients with truly refractory shock, routine use in all patients requiring vasopressors has not demonstrated clear mortality benefit. 1

Recent evidence suggests that early vasopressin addition (within 3 hours of norepinephrine initiation) may reduce time to shock resolution, which could potentially reduce the need for steroids altogether. 3 This supports aggressive vasopressor optimization before resorting to corticosteroids. 3