How to Choose the Right Pressor for Septic Shock?

A guide on selecting pressors for septic shock, focusing on safety and efficacy.

2 minute read

Overview

When patients with septic shock fail to respond to norepinephrine, determining which pressor to add next is crucial for maintaining adequate blood pressure and perfusion. The right choice can significantly impact patient outcomes and prevent complications.

NPS-adv

Clinical practice

First line

Lean toward adding a second pressor when the norepinephrine dose nears 0.3 mcg/kg/min BEFORE reaching the max dose to minimize side effects, such as arrhythmias. Doses over 1 mcg/kg/min are associated with high mortality. There's not a "one-size-fits-all" approach when using pressors to treat septic shock. Consider these factors when adding a second pressor.

Vasopressin. Usually add vasopressin first. There's no proof it's a better add-on than epinephrine, but limited evidence suggests vasopressin use may be associated with lower mortality. Don't generally go above vasopressin 0.04 units/min.

You can increase vasopressin up to 0.06 units/min as "salvage therapy" in nonresponsive patients if trying to avoid adding a third pressor. But higher doses may result in ischemia without known benefit.
Keep in mind that vasopressin is significantly more expensive per day compared to epinephrine or norepinephrine, which are much more affordable.
Use smaller bags, such as 20 units in 100 mL, to minimize waste.

Others

Epinephrine. For patients with low cardiac output, consider adding epinephrine instead of vasopressin. Epinephrine can increase heart rate and contractility. Don't rely on lactate when evaluating your patient's response to epinephrine, it can temporarily increase lactate levels.
Phenylephrine. Limit phenylephrine to patients with arrhythmias from norepinephrine or epinephrine. There's less evidence to support its benefit in septic shock, but it doesn't increase heart rate.
Angiotensin II. Save angiotensin II as a third-line, add-on option. It hasn't been studied first-line or compared to other add-on pressors and it is significantly more expensive per day.
Dopamine. Save dopamine for patients with bradycardia. It causes more arrhythmias than norepinephrine in patients with septic shock.

NPS-adv

References

Sacha GL, Bauer SR, Lat I. Vasoactive Agent Use in Septic Shock: Beyond First-Line Recommendations. Pharmacotherapy. 2019;39(3):369-381.
Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017;45(3):486-552.
Wakefield BJ, Busse LW, Khanna AK. Angiotensin II in Vasodilatory Shock. Crit Care Clin. 2019;35(2):229-245.
Jiang L, Sheng Y, Feng X, Wu J. The effects and safety of vasopressin receptor agonists in patients with septic shock: a meta-analysis and trial sequential analysis. Crit Care. 2019;23(1):91.

This note has been edited and reviewed by the pharmacy doctors on NPS team.