What is the recommended management for blood pressure in septic shock?

Blood Pressure Management in Septic Shock

Target a mean arterial pressure (MAP) of 65 mmHg using norepinephrine as the first-line vasopressor, initiated immediately after fluid resuscitation with at least 30 mL/kg of crystalloids in the first 3 hours. 1

Initial Resuscitation and Vasopressor Initiation

Fluid resuscitation must precede or accompany vasopressor therapy:

• Administer a minimum of 30 mL/kg of crystalloids within the first 3 hours for sepsis-induced tissue hypoperfusion 1
• Continue fluid challenge technique as long as hemodynamic improvement occurs based on dynamic (pulse pressure variation, stroke volume variation) or static (arterial pressure, heart rate) variables 1
• Do not delay norepinephrine initiation if life-threatening hypotension persists despite ongoing fluid resuscitation 2

Norepinephrine administration protocol:

• Establish central venous access for safe administration 2, 3
• Place an arterial catheter for continuous blood pressure monitoring as soon as practical 1, 3
• Target MAP ≥65 mmHg in most patients 1, 3
• In patients with chronic hypertension, consider targeting MAP of 80-85 mmHg to minimize renal injury, though this increases arrhythmia risk 4

Escalation for Refractory Hypotension

When norepinephrine alone fails to achieve target MAP, follow this escalation sequence:

Second-line agent - Add vasopressin:

• Add vasopressin at 0.03 units/minute (range 0.01-0.03 units/min) to raise MAP or decrease norepinephrine requirements 1, 2
• Never use vasopressin as monotherapy—it must be added to norepinephrine 1, 2, 3
• Do not exceed 0.03-0.04 units/minute except as salvage therapy when other vasopressors have failed 1, 2, 3
• FDA-approved dosing for septic shock starts at 0.01 units/minute, titrated up by 0.005 units/minute at 10-15 minute intervals 5

Third-line agent - Add epinephrine:

• Add epinephrine when additional vasopressor support is needed beyond norepinephrine and vasopressin 1, 3
• FDA-approved dosing: 0.05-2 mcg/kg/min IV infusion, titrated every 10-15 minutes to achieve desired MAP 6

Consider inotropic support:

• Add dobutamine (up to 20 mcg/kg/min) if persistent hypoperfusion exists despite adequate fluid loading and vasopressor therapy, particularly with evidence of myocardial dysfunction 1, 3

Agents to Avoid

Dopamine should NOT be used as first-line therapy:

• Use dopamine only in highly selected patients with low risk of tachyarrhythmias or absolute/relative bradycardia 1, 2
• Dopamine is associated with higher mortality and more arrhythmias compared to norepinephrine 2, 3
• Never use low-dose dopamine for renal protection—this is strongly discouraged 1, 2

Phenylephrine is not recommended except in specific circumstances:

• Only use when norepinephrine causes serious arrhythmias, cardiac output is documented high with persistently low blood pressure, or as salvage therapy when all other agents have failed 1, 3

Adjunctive Therapy for Refractory Shock

Corticosteroid consideration:

• Do not use intravenous hydrocortisone if adequate fluid resuscitation and vasopressor therapy restore hemodynamic stability 1, 7
• Consider hydrocortisone 200 mg/day only when hemodynamic stability cannot be achieved despite adequate fluid resuscitation and escalating vasopressor support 3, 7
• The decision is based on hemodynamic response, not a predetermined vasopressor dose cutoff 7
• Taper hydrocortisone when vasopressors are no longer required 7

Critical Monitoring and Titration

Monitor beyond MAP alone:

• Assess markers of tissue perfusion: lactate clearance, urine output, mental status, and skin mottling 2, 3
• Recent evidence suggests that if achieving higher MAP requires high norepinephrine doses or fails to resolve mottled skin at 24 hours, this may be associated with increased mortality 8
• Pulse pressure >48 mmHg during initial resuscitation is independently associated with higher 28-day mortality, even when MAP is maintained >65 mmHg 9

Vasopressor weaning strategy:

• After hemodynamic stabilization for 8 hours without catecholamines, taper vasopressin by 0.005 units/minute every hour as tolerated 5
• For epinephrine, wean incrementally over 12-24 hours, decreasing doses every 30 minutes 6
• Titrate to the lowest dose compatible with adequate organ perfusion, not supranormal blood pressure targets 3

Common Pitfalls to Avoid

• Do not delay norepinephrine waiting to complete entire fluid resuscitation if life-threatening hypotension exists 2
• Do not escalate vasopressin beyond 0.03-0.04 units/minute—add epinephrine instead 2, 3
• Do not rely solely on MAP as a surrogate of organ perfusion—monitor lactate, urine output, and clinical perfusion markers 2, 3
• Do not use dopamine as first-line therapy—evidence clearly favors norepinephrine 2, 3
• Avoid excessive vasoconstriction—monitor for digital ischemia, decreased urine output, or rising lactate despite adequate MAP 3