From the Guidelines
Norepinephrine is the first-line vasopressor agent to be initiated in patients with septic shock, as it is more efficacious than dopamine and may be more effective for reversing hypotension in these patients 1, 2, 3, 4.
Order of Initiating Vasopressors
- Norepinephrine is the initial vasopressor of choice, with a recommended dose of 0.01-0.5 μg/kg/min 5.
- Epinephrine can be added to and potentially substituted for norepinephrine when an additional agent is needed to maintain adequate blood pressure 1, 2.
- Vasopressin can be added to norepinephrine with the intent of either raising mean arterial pressure (MAP) or decreasing norepinephrine dosage, at a dose of 0.03 units/minute 1, 2.
- Dopamine can be used as an alternative vasopressor agent to norepinephrine only in highly selected patients, such as those with low risk of tachyarrhythmias and absolute or relative bradycardia 1, 2, 3, 4.
- Phenylephrine is not recommended in the treatment of septic shock except in specific circumstances, such as when norepinephrine is associated with serious arrhythmias or as salvage therapy when combined inotrope/vasopressor drugs and low-dose vasopressin have failed to achieve MAP target 1, 2. The goal of vasopressor therapy is to target a mean arterial pressure (MAP) of 65 mm Hg 1, 2, 5, 3, 4.
From the Research
Order of Initiating Vasopressors
The order of initiating vasopressors, also known as pressors, is a critical aspect of managing patients with shock. According to the available evidence, the following order is recommended:
- Norepinephrine is the first-choice vasopressor in vasodilatory shock after adequate volume resuscitation 6, 7, 8
- In patients not responsive to norepinephrine, vasopressin or epinephrine may be added 6, 7
- Angiotensin II may be useful for rapid resuscitation of profoundly hypotensive patients 6, 7
- Dopamine is recommended only in bradycardic patients or when other vasopressors are not available 6, 7, 8
Key Considerations
When initiating vasopressors, the following key considerations should be taken into account:
- The choice of vasopressor and dose vary widely due to patient and physician practice heterogeneity 6, 7
- Vasopressors should be administered simultaneously with fluid replacement to prevent and decrease duration of hypotension in shock with vasodilation 7
- The goal of therapy is to increase blood pressure and maintain adequate perfusion, allowing nutrient and oxygen delivery to vital organs 8
- Adverse effects of vasopressors include excessive vasoconstriction, organ ischemia, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias 6, 7
Variability in Practice Patterns
There is significant variability in practice patterns for initiating secondary vasopressors and adjunctive corticosteroids during septic shock 9. The hospital of admission is strongly associated with receiving an additional-vasopressor-first strategy over a corticosteroid-first strategy 9. Further studies are needed to improve septic shock management and reduce variability in practice patterns.