Norepinephrine in septic shock: when and how much?

PURPOSE OF REVIEW: Norepinephrine is the first-line agent recommended during resuscitation of septic shock to correct hypotension due to depressed vascular tone. Important clinical issues are the best timing to start norepinephrine, the optimal blood pressure target, and the best therapeutic options to face refractory hypotension when high doses of norepinephrine are required to reach the target. RECENT FINDINGS: Recent literature has reported benefits of early administration of norepinephrine because of the following reasons: profound and durable hypotension is an independent factor of increased mortality, early administration of norepinephrine increases cardiac output, improves microcirculation and avoids fluid overload. Recent data are in favor of targeting a mean arterial pressure of at least 65 mmHg and higher values in case of chronic hypertension. When hypotension is refractory to norepinephrine, it is recommended adding vasopressin, which is relatively deficient during sepsis and acts on other vascular receptors than α1-adernergic receptors. However, increasing the dose of norepinephrine further cannot be discouraged. SUMMARY: Early administration of norepinephrine is beneficial for septic shock patients to restore organ perfusion. The mean arterial pressure target should be individualized. Adding vasopressin is recommended in case of shock refractory to norepinephrine.