Vasopressor Support in Septic Shock

Steven M. Hollenberg
When fluid administration fails to restore an adequate arterial pressure and organ perfusion in patients with septic shock, therapy with vasopressor agents should be initiated. The ultimate goals of such therapy in patients with shock are to restore effective tissue perfusion and to normalize cellular metabolism. Although arterial pressure is the end point of vasopressor therapy, and the restoration of adequate pressure is the criterion of effectiveness, BP does not always equate to blood flow; so, the precise BP goal to target is not necessarily the same in all patients. There has been longstanding debate about whether one catecholamine vasopressor agent is superior to another, but different agents have different effects on pressure and flow. The argument about which catecholamine is best in a given situation is best transformed into a discussion about which agent is best suited to implement the therapeutic strategy chosen. Despite the complex pathophysiology of sepsis, an underlying approach to its hemodynamic support can be formulated that takes both pressure and perfusion into account when choosing therapeutic interventions. The efficacy of hemodynamic therapy in sepsis should be assessed by monitoring a combination of clinical and hemodynamic parameters. How to optimize regional blood and microcirculatory blood flow remains uncertain. Thus, specific end points for therapy are debatable and are likely to evolve. Nonetheless, the idea that clinicians should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis remains a fundamental principle.