What is the recommended first-line vasopressor for sepsis/septic shock?

Updated: Oct 07, 2020
  • Author: Andre Kalil, MD, MPH; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM  more...
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The recommended first-line agent for septic shock is norepinephrine, preferably administered through a central catheter. [11, 60] Norepinephrine has predominant alpha-receptor agonist effects and results in potent peripheral arterial vasoconstriction without significantly increasing heart rate or cardiac output. The dosage range for norepinephrine is 5-20 µg/min, and it is not based on the weight of the patient.

Norepinephrine is preferred to dopamine for managing septic shock because dopamine is known to cause unfavorable flow distribution (more arrhythmias). In this setting, norepinephrine has been shown to be both significantly safer and somewhat more effective.

In a systematic review of randomized controlled trials, norepinephrine was significantly superior to dopamine in improving both in-hospital and 28-day mortality in septic shock patients. [88] In a meta-analysis that evaluated these 2 agents in the setting of septic shock, the investigators determined that in comparison with dopamine, epinephrine was associated with a decreased risk of death and a lower incidence of arrhythmic events. [89]

In theory, norepinephrine is the ideal vasopressor in the setting of warm shock, wherein peripheral vasodilation exists in association with normal or increased cardiac output. The typical patient with warm shock has warm extremities but exhibits systemic hypotension and tachycardia, the results of decreased systemic vascular resistance.

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