Norepinephrine for Septic Shock in High-Risk Surgical Patients

Introduction to Norepinephrine Use

The American College of Critical Care Medicine recommends norepinephrine as the first-line vasopressor for septic shock, as it is life-saving in this clinical scenario 1, 2, 3
Norepinephrine should be started as soon as hypotension persists despite initial fluid resuscitation, with a target mean arterial pressure (MAP) of 65 mmHg initially, though this may be adjusted based on patient history 1, 2, 3, 5

The Surviving Sepsis Campaign guidelines recommend targeting a MAP of 65 mmHg, with higher targets for patients with chronic hypertension, such as 70-75 mmHg 1, 2, 3
Norepinephrine dosing should start at 0.02-0.05 μg/kg/min and be titrated to achieve target MAP, with a maximum dose of 0.1-0.2 μg/kg/min 5
Vasopressin can be added at 0.03 units/minute if MAP target cannot be achieved with norepinephrine alone, but should not be used as monotherapy 1, 2, 4, 5

Patients with chronic hypertension require higher MAP targets and should be monitored closely for end-organ perfusion markers such as lactate clearance, urine output, mental status, and capillary refill 1, 2, 3, 5
The World Journal of Emergency Surgery recommends maintaining MAP ≥65 mmHg during surgery to reduce end-organ injury, including acute kidney injury and myocardial injury 6

Dopamine is associated with higher mortality and more arrhythmias compared to norepinephrine, and should only be considered in highly selected patients with low risk of tachyarrhythmias or absolute bradycardia 1, 2, 4, 5
Phenylephrine may raise blood pressure numbers while actually worsening tissue perfusion through excessive vasoconstriction, and should only be used in specific circumstances such as serious arrhythmias or cardiac output is documented high with persistent hypotension 1, 2, 4, 5