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Vasopressor Selection in Septic Shock

Vasopressor Selection in Septic Shock: Adult Septic Shock: Choosing Vasopressors → Check First: Adult Septic Shock Only; Pregnancy; MAOI, Linezolid, Tri...

Pathway Overview

15 steps

Algorithm Steps

15 total

  1. 01Start

    Adult Septic Shock: Choosing Vasopressors

    Adult with septic shock. Start a vasopressor if hypotension persists after initial IV crystalloid. Unstable shock: start it during fluid resuscitation.

  2. 02Warning

    Check First: Adult Septic Shock Only; Pregnancy; MAOI, Linezolid, Tricyclics

    Other shock types and children need a different approach. Pregnancy: noradrenaline stays first line, target MAP 65 mmHg; use left uterine displacement and involve the obstetric team.

    • Cardiogenic, obstructive (PE, tamponade) or haemorrhagic shock: this pathway does not apply
    • Children: all doses here are adult doses. Use paediatric sepsis guidance
    • MAOI, linezolid or tricyclic antidepressant: noradrenaline can cause severe, prolonged hypertension. Use extreme caution
  3. 03Action

    Start Noradrenaline (First Line)

    SSC 2026: noradrenaline over dopamine or adrenaline (strong). Start it peripherally rather than wait for a central line.

    • Adult: start 8-12 microgram/min (as base), then titrate to the MAP target. Ampoule 1 mg/mL; dilute per local protocol
    • Peripheral line: large vein at or above the antecubital fossa, short term only. Check the site often for extravasation
    • Extravasation: infiltrate phentolamine 5-10 mg in 10-15 mL sodium chloride 0.9% into the area as soon as possible. Australia: phentolamine is not TGA-registered (SAS access); follow the local extravasation protocol
    • Place an arterial line as soon as practical
    • Known cardiac dysfunction: noradrenaline or adrenaline first line. Tachyarrhythmia: prefer noradrenaline. Bradycardia: prefer adrenaline
    • Do not use dopamine: more arrhythmias and higher mortality than noradrenaline
  4. 04Decision

    MAP at Target?

    Target MAP 65 mmHg, kept within about 5 mmHg. Age 65 years or older: 60-65 mmHg.

  5. If Yes
    1. 05Action

      MAP at Target: Reassess Perfusion

      Keep vasopressors at the lowest dose that holds the MAP target.

      • Reassess fluid responsiveness with dynamic measures before more fluid
      • Trend lactate and capillary refill time
      • Check source control and other causes of shock
      • Noradrenaline need persists: start IV hydrocortisone (see hydrocortisone step)
    2. 06Decision

      Poor Perfusion With Cardiac Dysfunction?

      MAP at target and volume adequate, but hypoperfusion persists and echo shows cardiac dysfunction.

    3. If Yes
      1. 07Action

        MAP at Target, Low Output: Add Dobutamine or Use Adrenaline

        Only when MAP is at target: dobutamine can cause vasodilation and drop MAP. LV outflow obstruction on echo (HOCM, dynamic LVOTO, Takotsubo with LVOTO): do not use dobutamine or adrenaline; get ICU or cardiology advice.

        • Option 1: add dobutamine to noradrenaline. Adult: usual 2.5-10 microgram/kg/min; rarely up to 40 microgram/kg/min (PI maximum). Use the lowest effective dose
        • Option 2: switch to adrenaline alone
        • Inotropes add to vasopressors; they do not replace them
        • Watch for tachyarrhythmia and myocardial ischaemia
        • SSC 2026 suggests against levosimendan
      2. 08Outcome

        Stable: Wean Vasoactive Drugs

        MAP at target and perfusion improving. Wean as tolerated and keep reassessing.

      If No
      1. Path rejoins step 08Shared downstream outcome
    If No
    1. 09Action

      MAP Below Target: Increase Noradrenaline

      Titrate noradrenaline to the MAP target. Recheck the line, volume status and source control.

      • Noradrenaline 0.25 microgram/kg/min = 17.5 microgram/min for a 70 kg adult
      • Dose rising, usually at 0.25-0.5 microgram/kg/min: add vasopressin (next step)
    2. 10Action

      Noradrenaline Dose Rising: Add Vasopressin

      Only if noradrenaline need keeps rising (usually 0.25-0.5 microgram/kg/min). MAP at target on noradrenaline alone: go to 'MAP at Target'. SSC 2026: suggest adding vasopressin (moderate certainty). Caution in coronary or peripheral vascular disease.

      • Adult: 0.03 units/min fixed dose. Do not titrate it like noradrenaline
      • Higher doses are linked to cardiac, digital and gut ischaemia
      • Australia: argipressin 20 units/mL. IV infusion for septic shock is off-label
      • Vasopressin not available: add adrenaline to noradrenaline instead
    3. 11Action

      Noradrenaline Need Persists: Start IV Hydrocortisone

      SSC 2026 suggests IV corticosteroids in septic shock. Strongyloides exposure risk: send serology and ask ID about ivermectin; do not delay hydrocortisone.

      • Adult: hydrocortisone 200 mg/day IV, as 50 mg every 6 h or a continuous infusion
      • SSC 2021 start point: noradrenaline or adrenaline 0.25 microgram/kg/min or more for at least 4 h
      • With or without fludrocortisone 50 microgram enterally once daily
      • Usually 5-7 days; a taper is optional
    4. 12Decision

      MAP Still Below Target on Noradrenaline and Vasopressin?

      Recheck MAP after vasopressin has started.

    5. If Yes
      1. 13Action

        MAP Still Low: Add Adrenaline (Third Line)

        SSC 2026: suggest adding adrenaline (very low certainty). LV outflow obstruction on echo: adrenaline can worsen it; get ICU or cardiology advice.

        • Adult: start 0.05 microgram/kg/min. Titrate by 0.05-0.2 microgram/kg/min every 10-15 min (US product label range 0.05-2 microgram/kg/min; Australian PI gives no septic shock dose)
        • Raises heart rate, blood glucose and lactate
        • Get an echo: check cardiac function and other causes of shock
      2. 14Decision

        MAP at Target After Adding Adrenaline?

        Recheck MAP and perfusion.

      3. If Yes
        1. Path rejoins step 05Shared downstream outcome
        If No
        1. 15Outcome

          Refractory Septic Shock: ICU Consultant Review

          Recheck source control, volume status, echo and other shock causes. SSC 2026: no recommendation on methylene blue; suggests against terlipressin. Discuss goals of care.

      If No
      1. Path rejoins step 05Shared downstream outcome

Guideline Source

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026

DOI: 10.1097/CCM.0000000000007075View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults with septic shock only. Not for children, or for cardiogenic, obstructive or haemorrhagic shock.
  • Doses are adult doses from product information and SSC; follow local ICU infusion concentrations and protocols.
  • Pregnancy: noradrenaline first line and MAP 65 mmHg (SOMANZ 2023); involve the obstetric and ICU teams.
  • Evidence for third-line vasopressors and inotropes is low or very low certainty (SSC 2026).
  • Does not replace echo or invasive haemodynamic monitoring when indicated.

Contraindicated Populations

pediatricneonatal

Applicable Regions

AUUSEUGlobal

AU: Noradrenaline ampoules are 1 mg/mL (doses as base); many ICUs prescribe in microgram/min. Argipressin 20 units/mL is TGA-registered, but IV infusion for septic shock is off-label.

Global: SSC 2026 (SCCM/ESICM) international sepsis guideline.

Version 2Next review: 2027-09-30

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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 2026.

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 2026 (DOI: 10.1097/CCM.0000000000007075).

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

Known limitations include: Adults with septic shock only. Not for children, or for cardiogenic, obstructive or haemorrhagic shock.; Doses are adult doses from product information and SSC; follow local ICU infusion concentrations and protocols.; Pregnancy: noradrenaline first line and MAP 65 mmHg (SOMANZ 2023); involve the obstetric and ICU teams.; Evidence for third-line vasopressors and inotropes is low or very low certainty (SSC 2026).; Does not replace echo or invasive haemodynamic monitoring when indicated.. Individual patient factors may require deviation from these recommendations.

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