The information on this website is not intended for diagnosis or treatment. Please consult your physician for health concerns.

+90 850 321 50 00

Norepinephrine and Vasopressin — Vasopressor Selection Strategy in Septic Shock

Norepinephrine as first-line therapy, addition of vasopressin, and combination strategies in septic shock.

Written by: Saygı Hospital Health Guide Editorial Board
Published: · Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (3)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Kardiyoloji department. Book Appointment →

What is Norepinephrine and Vasopressin — Vasopressor Selection Strategy in Septic Shock?

Vasopressor therapy in septic shock is initiated when MAP <65 persists after adequate fluid resuscitation (30 mL/kg crystalloid). The aim is to protect organ perfusion (target MAP 65-75; individualize in the elderly or those with a history of hypertension).

Norepinephrine — first choice (SSC 2021, strong recommendation). It has α1 (vasoconstriction) + β1 (cardiac output) effects. Dose 0.05-0.5 mcg/kg/min; a central venous line is preferred (avoid prolonged peripheral use to prevent vascular injury). Arrhythmia risk is lower than with other catecholamines.

Vasopressin — add at a fixed dose of 0.03 U/min if MAP <65 persists on norepinephrine monotherapy (not titrated). Acts via V1a receptors for non-adrenergic vasoconstriction and corrects the 'relative vasopressin deficiency' of sepsis. VASST (2008, NEJM) showed no mortality increase and reduced arrhythmia risk.

Epinephrine — second/third-line in refractory shock. β2 effects include bronchodilation + tachycardia; β1 provides cardiac effect. A side effect is elevated lactate (misleading for lactate trending). Angiotensin II (Giapreza) — a reserve agent approved in 2018, acting on V1a and AT1 receptors. Methylene blue is another option in refractory cases.

Symptoms

Septic shock diagnosis — fluid-unresponsive hypotension (MAP <65 after 30 mL/kg crystalloid), lactate >2 mmol/L, organ dysfunction
High vasopressor requirement — norepinephrine >0.25 mcg/kg/min → add vasopressin, consider steroid
Arrhythmia tendency — AF, premature beats → prefer vasopressin, avoid epinephrine
Shock-type differentiation — distributive (sepsis/anaphylaxis), cardiogenic, hypovolemic, obstructive; select vasopressor by shock type
Lactate >4 + MAP <65 → start aggressive vasopressor; respect targets

Risk Factors

High-dose monotherapy (norepinephrine >0.5) — risk of limb, mesenteric, and cardiac ischemia
Arrhythmia-prone patient — AF history, structural heart disease, electrolyte disturbance
Ischemic heart disease — high-dose vasopressors can worsen myocardial ischemia; inotropes require care
Pulmonary hypertension — vasopressin may raise PVR, risking right-heart failure
Peripheral vascular disease — prolonged high-dose norepinephrine can cause distal ischemia

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • MAP <65 after fluid resuscitation — start vasopressors immediately (central venous line ideal)
  • Norepinephrine 0.25-0.5 mcg/kg/min — add vasopressin 0.03 U/min and consider steroid
  • Despite maximum combination therapy MAP remains <65 (refractory) — consider epinephrine, angiotensin II, methylene blue, and multi-organ support

Treatment Methods

01
First step — start norepinephrine at 0.05 mcg/kg/min, titrate to a MAP target of 65-75 (0.025-unit increments every 5-10 minutes); central venous line preferred (jugular/subclavian)
02
Second agent — if MAP <65 despite norepinephrine at 0.25-0.5 mcg/kg/min, add vasopressin at a fixed 0.03 U/min (not titrated; some protocols go up to 0.04) and aim to reduce norepinephrine
03
Steroid — after increasing vasopressors, add hydrocortisone 200 mg/day (50 mg × 4 or continuous infusion); CORTICUS and APROCCHSS meta-analyses show shorter shock duration with mixed mortality findings
04
Refractory shock — add epinephrine 0.05-0.5 mcg/kg/min. Angiotensin II (ATHOS-3, NEJM 2017) starts at 20 ng/kg/min, may reach 200 ng/kg/min
05
Monitoring — continuous MAP, ECG (arrhythmia), lactate every 2-4 hours (trend), urine output, mental status, distal perfusion (extremities, capillary refill)
06
Weaning — stable MAP + lactate <2 + clear mental status → reduce norepinephrine toward 0.02 mcg/kg/min (every 2-4 hours), then wean vasopressin (do not stop suddenly — risk of hypotension). Taper steroids over 2-3 days

Which Department to Visit?

You can visit our Kardiyoloji department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

Learn About Kardiyoloji Department

Let us help you

You can make an appointment with our specialists or contact us for your concerns.

Book AppointmentContact Us

Related Health Topics

Other articles from the same department you may want to explore.

Hypertension (High Blood Pressure)

Kardiyoloji

Hypertension is a condition in which blood pressure readings remain above 140/90 mmHg; early treatment helps prevent serious complications.

Coronary Artery Disease

Kardiyoloji

Narrowing of the coronary arteries due to atherosclerosis can cause chest pain (angina) and heart attack.

Heart Failure

Kardiyoloji

Heart failure is a chronic cardiac condition characterized by shortness of breath, leg swelling, and fatigue.

Heart Attack (Myocardial Infarction)

Kardiyoloji

A heart attack is a medical emergency; because heart muscle is lost by the minute, immediate intervention saves lives.

Atrial Fibrillation

Kardiyoloji

Atrial fibrillation is a common arrhythmia characterized by an irregular heartbeat and increased risk of stroke.

Heart Palpitations

Kardiyoloji

Palpitations are usually due to benign causes, but underlying cardiac rhythm disorders must be ruled out.

Heart Valve Diseases

Kardiyoloji

Valve stenosis or regurgitation increases the workload of the heart and, over time, can lead to heart failure.

Aortic Aneurysm

Kardiyoloji

Aortic aneurysms are often silent; early diagnosis allows treatment before rupture (a life-threatening tear).

Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.