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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...

Pathway Overview

14 steps

Algorithm Steps

14 total

  1. 01Start

    Septic Shock with Hypotension

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

  2. 02Action

    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
  3. 03Decision

    MAP Goal Achieved?

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

  4. 04Action

    Continue Current Therapy

    Monitor and titrate to lowest effective dose

    • Reassess volume status
    • Monitor lactate clearance
    • Assess perfusion (UOP, cap refill, mental status)
  5. 05Outcome

    Hemodynamically Stable

    Wean vasopressors as tolerated

  6. 06Decision

    NE Dose Threshold?

    Norepinephrine reaching 0.25-0.5 mcg/kg/min

  7. 07Action

    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
  8. 08Decision

    MAP Still Inadequate?

    Persistent hypotension despite NE + vasopressin

  9. 09Decision

    Evidence of Low CO?

    Echo shows depressed LV function, low ScvO2

  10. 10Action

    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
  11. 11Action

    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
  12. Path rejoins step 05Shared downstream outcome
  13. 12Outcome

    Refractory Shock

    Consider mechanical support, palliative care discussion

  14. 13Action

    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)
  15. Path rejoins step 11Shared downstream outcome
  16. Path rejoins step 04Shared downstream outcome
  17. 14Warning

    ⚠️ 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
  18. Path rejoins step 02Shared downstream outcome

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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