Do I titrate up one vasopressor (pressor) at a time?

Vasopressor Titration Strategy

Start with norepinephrine as your sole first-line vasopressor and titrate it up alone to achieve a MAP ≥65 mmHg before adding a second agent. 1, 2, 3

Sequential Vasopressor Escalation Protocol

Step 1: Optimize Norepinephrine First

• Initiate norepinephrine at 0.02 mcg/kg/min and titrate upward as a single agent to achieve MAP ≥65 mmHg. 2
• Continue titrating norepinephrine up to 0.1-0.2 mcg/kg/min (approximately 15 mcg/min in a 70 kg patient) before considering a second vasopressor. 2, 3
• The Surviving Sepsis Campaign guidelines establish norepinephrine as the mandatory first-choice vasopressor, and there is no compelling evidence to support starting multiple vasopressors simultaneously. 1

Step 2: Add Vasopressin as Second Agent

• When norepinephrine alone fails to achieve target MAP despite adequate fluid resuscitation, add vasopressin at 0.03 units/minute—do not increase norepinephrine further. 1, 2, 3, 4
• The FDA-approved dosing for vasopressin in septic shock starts at 0.01 units/minute, titrated by 0.005 units/minute every 10-15 minutes up to 0.03 units/minute. 4
• Vasopressin should never be used as initial monotherapy—it must be added to norepinephrine, not substituted for it. 1, 2, 3

Step 3: Add Epinephrine as Third Agent if Needed

• If hypotension persists despite norepinephrine plus vasopressin, add epinephrine (0.05-2 mcg/kg/min) as your third vasopressor. 2, 3
• Epinephrine is particularly useful when myocardial dysfunction contributes to shock, given its inotropic effects. 1, 2

Critical Pitfalls to Avoid

Do Not Escalate Vasopressin Beyond 0.03-0.04 Units/Minute

• Vasopressin doses above 0.03-0.04 units/minute cause cardiac, digital, and splanchnic ischemia and should be reserved only for salvage therapy when all other options have failed. 3
• The FDA label explicitly states there are limited data for vasopressin doses above 0.07 units/minute in septic shock, and adverse reactions increase with higher doses. 4

Do Not Use Dopamine

• Dopamine should not be used except in highly selected patients with absolute bradycardia and low risk of tachyarrhythmias—it causes more arrhythmias and higher mortality compared to norepinephrine. 1, 2, 3, 5
• The Surviving Sepsis Campaign explicitly recommends against dopamine as first-line therapy. 1

Do Not Start Multiple Vasopressors Simultaneously

• The sequential approach allows you to assess response to each agent individually and minimizes the risk of excessive vasoconstriction from additive effects. 2, 3
• Starting multiple vasopressors at once makes it impossible to determine which agent is effective and increases the risk of adverse effects. 3

Monitoring Requirements During Titration

• Place an arterial catheter as soon as practical for continuous blood pressure monitoring in all patients requiring vasopressors. 1, 2, 3, 5
• Monitor not just MAP, but also lactate clearance, urine output, mental status, skin perfusion, and capillary refill to assess tissue perfusion. 2, 3
• Ensure adequate fluid resuscitation (minimum 30 mL/kg crystalloid) before or concurrent with vasopressor initiation. 1, 2, 3, 5

When to Add Inotropic Support

• If persistent hypoperfusion exists despite adequate MAP and vasopressor therapy, add dobutamine (2.5-20 mcg/kg/min) rather than escalating vasopressors further. 1, 2, 3
• Dobutamine is indicated when myocardial dysfunction is evident with low cardiac output despite adequate filling pressures. 1, 2