Surviving Sepsis Campaign 2021 · Reviewed by a PharmD, BCCCP · Updated Jul 2026
Target MAP ≥65 mmHg (individualize; some chronic-HTN patients need 70–80). Ensure adequate volume resuscitation alongside. Don't wait for fluids to fail before starting norepinephrine.
Escalation Ladder
1
Norepinephrine: first-line. 0.01–3 mcg/kg/min (typical 0.1–0.5). Alpha₁ >> beta₁. SSC 2021: strong recommendation, moderate-quality evidence. Central line preferred; brief peripheral use via a large proximal vein is acceptable in emergencies.
2
Add vasopressin when NE ≈ 0.25–0.5 mcg/kg/min. Fixed 0.03 units/min (up to 0.04), not titrated. SSC 2021: weak recommendation (suggest), moderate-quality. VASST: no overall mortality benefit; post-hoc benefit in less-severe shock.
Add hydrocortisone if NE (or equiv) ≥0.25 mcg/kg/min for ≥4 h despite adequate fluids. 200 mg/day IV (50 mg q6h or continuous). APROCCHSS (benefit, with fludrocortisone) / ADRENAL (faster weaning, no mortality signal). SSC 2021: weak recommendation.
Agent Reference
Agent
Dose
Role / Note
Norepinephrine
0.01–3 mcg/kg/min
First-line
Vasopressin
0.03 units/min (fixed)
NE-sparing add-on; not titrated
Epinephrine
0.01–0.5 mcg/kg/min
Refractory; may raise lactate (beta₂)
Angiotensin II
20–80 ng/kg/min
Refractory; high-renin phenotype
Dopamine
2–20 mcg/kg/min
Not preferred; ↑ arrhythmia (De Backer 2010)
Red Flags & Pearls
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Avoid phenylephrine in septic shock (pure alpha, no inotropy, can drop cardiac output). Role is limited to post-cardiac-surgery vasoplegia.