Norepinephrine Initiation in Septic Shock

Initial Approach to Septic Shock Management

The Society of Critical Care Medicine recommends beginning with rapid fluid resuscitation using crystalloids at 30 mL/kg within the first 3 hours for patients with sepsis-induced hypoperfusion 1, 3
The European Society of Intensive Care Medicine suggests continuing fluid administration as long as hemodynamic parameters improve (using dynamic or static variables) 1
The American College of Critical Care Medicine recommends targeting a mean arterial pressure (MAP) of 65 mmHg as the initial goal for vasopressor therapy 2, 3
Monitoring for signs of adequate perfusion, including mental status, capillary refill, lactate clearance, and urine output, is recommended by the Society of Critical Care Medicine 2, 3

The Society of Critical Care Medicine recommends starting norepinephrine when persistent hypotension despite initial fluid challenge occurs 2, 4
The European Society of Intensive Care Medicine suggests starting norepinephrine when diastolic blood pressure is critically low, threatening organ perfusion 2

The Mayo Clinic recommends initial dosing of norepinephrine at 0.02-0.05 μg/kg/min and titrating to maintain target MAP ≥65 mmHg 5
The Society of Critical Care Medicine recommends placing an arterial catheter as soon as practical for continuous blood pressure monitoring 1

The Society of Critical Care Medicine recommends considering adding vasopressin (up to 0.03 U/min) to either raise MAP or decrease norepinephrine requirements if hypotension persists despite norepinephrine at 0.1-0.2 μg/kg/min 1, 3, 5
The European Society of Intensive Care Medicine suggests considering adding epinephrine as an alternative second agent 1, 3
The Mayo Clinic recommends considering hydrocortisone 200 mg/day (as 50 mg IV every 6 hours) if no response to vasopressors after 4 hours 5

The Society of Critical Care Medicine recommends avoiding relying solely on fluid resuscitation in profound shock as this may prolong hypotension and worsen outcomes 1
The European Society of Intensive Care Medicine suggests avoiding phenylephrine except in specific circumstances (norepinephrine-associated arrhythmias, high cardiac output with persistent low BP, or as salvage therapy) 1, 3
The Society of Critical Care Medicine recommends not using low-dose dopamine for renal protection 1, 3