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Vasopressor Selection in Septic Shock

Vasopressor Selection in Septic Shock: Septic Shock with Hypotension → Start Norepinephrine (First-Line) → MAP Goal Achieved? → Continue Current Therapy...

Interactive Decision Tree

Mini Map

Algorithm Steps

  1. ▶
    Start

    Septic Shock with Hypotension

    MAP <65 mmHg despite adequate fluid resuscitation (30 mL/kg crystalloid)

    1. ●
      Action

      Start Norepinephrine (First-Line)

      Strong recommendation - SSC 2021

      • Start: 0.05-0.1 mcg/kg/min
      • Titrate to MAP ≥65 mmHg
      • Central line preferred but can start peripherally
      • Max typically 0.5-1 mcg/kg/min before adding agents
      1. ◆
        Decision

        MAP Goal Achieved?

        Target MAP ≥65 mmHg (or higher if chronic HTN)

        1. ●
          Action

          Continue Current Therapy

          Monitor and titrate to lowest effective dose

          • Reassess volume status
          • Monitor lactate clearance
          • Assess perfusion (UOP, cap refill, mental status)
          1. ✓
            Outcome

            Hemodynamically Stable

            Wean vasopressors as tolerated

        2. ◆
          Decision

          NE Dose Threshold?

          Norepinephrine reaching 0.25-0.5 mcg/kg/min

          1. ●
            Action

            Add Vasopressin

            Second-line agent (Weak recommendation)

            • Fixed dose: 0.03 units/min (up to 0.04)
            • Do NOT titrate like catecholamines
            • May allow reduction of NE dose
            • Caution: digital/mesenteric ischemia
            1. ◆
              Decision

              MAP Still Inadequate?

              Persistent hypotension despite NE + vasopressin

              1. ◆
                Decision

                Evidence of Low CO?

                Echo shows depressed LV function, low ScvO2

                1. ●
                  Action

                  Add Dobutamine

                  For persistent hypoperfusion with cardiac dysfunction

                  • Start: 2.5-5 mcg/kg/min
                  • Max: 20 mcg/kg/min
                  • Monitor for tachyarrhythmias
                  • May worsen hypotension initially
                  1. ●
                    Action

                    Consider Hydrocortisone

                    If ongoing vasopressor requirement

                    • 200 mg/day IV (50mg q6h or continuous)
                    • For refractory shock
                    • SCCM 2024: Conditional recommendation
                    • Duration: typically 5-7 days, taper
                    1. ✓
                      Outcome

                      Refractory Shock

                      Consider mechanical support, palliative care discussion

                2. ●
                  Action

                  Add Epinephrine

                  Third-line agent

                  • Start: 0.01-0.05 mcg/kg/min
                  • Titrate to effect
                  • Alternative to NE in some centers
                  • ⚠️ Increases lactate (aerobic glycolysis)
            2. ⚠
              Warning

              ⚠️ Avoid Dopamine

              Associated with increased arrhythmias vs NE

              • Exception: bradycardia with low risk of tachyarrhythmia
              • Higher mortality in RCTs vs norepinephrine
              • SSC 2021: Suggest against dopamine

Guideline Source

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021

DOI: 10.1007/s00134-021-06506-yView Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Does not address cardiogenic shock (different vasopressor hierarchy)
  • Assumes adequate fluid resuscitation has been attempted
  • Drug dosing may vary by institution
  • Does not replace invasive hemodynamic monitoring when indicated
  • Pediatric dosing differs significantly

Contraindicated Populations

pediatricneonatal

Applicable Regions

USEUGlobal

Global: SSC 2021 is internationally recognized

Version 1Next review: 2027-01-01

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Frequently Asked Questions

What is the Vasopressor Selection in Septic Shock?

The Vasopressor Selection in Septic Shock is a management clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021.

What guideline is the Vasopressor Selection in Septic Shock based on?

This algorithm is based on Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021 (DOI: 10.1007/s00134-021-06506-y).

What are the limitations of the Vasopressor Selection in Septic Shock?

Known limitations include: Does not address cardiogenic shock (different vasopressor hierarchy); Assumes adequate fluid resuscitation has been attempted; Drug dosing may vary by institution; Does not replace invasive hemodynamic monitoring when indicated; Pediatric dosing differs significantly. Individual patient factors may require deviation from these recommendations.

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