Noradrenaline is first-line. Target MAP 65 mmHg (60-65 in septic patients aged ≥ 65). Add vasopressin as noradrenaline doses escalate (commonly 0.25-0.5 mcg/kg/min), then adrenaline; consider steroids and look for a missed cause in refractory shock.
At the bedside
Timed steps- 1
Noradrenaline first
Start0.05-0.1 mcg/kg/min. Start through a good proximal peripheral cannula rather than delay while central access is placed (SSC 2026).
- 2
MAP 65 mmHg
TargetInitial target MAP 65, kept within ~5 mmHg (SSC 2026, strong). Higher (75-80) only if chronic hypertension with AKI is a concern. Septic shock aged ≥ 65: SSC 2026 suggests 60-65 (65 trial).
- 3
Every 5-10 min
TitrateIncrease in steps of 0.02-0.05 mcg/kg/min. Arterial line as soon as practical.
- 4
Add vasopressin
EscalateAs noradrenaline doses escalate (commonly 0.25-0.5 mcg/kg/min), add vasopressin 0.03 units/min (SSC 2026). VASSPR (2026): starting at 0.1 vs 0.4 made no mortality difference.
- 5
Add adrenaline
EscalateIf MAP is still inadequate, or LV dysfunction: adrenaline 0.05-0.3 mcg/kg/min (can be added to noradrenaline alone if vasopressin is unavailable). Septic shock: hydrocortisone 200 mg/day for ongoing vasopressor need (module 4).
- 6
Rethink
Refractory> 0.5-1 mcg/kg/min total: echo (LV, RV, tamponade, LVOT obstruction), bleeding, adrenal insufficiency, hypocalcaemia, acidosis, uncontrolled source, drug error (wrong dilution). Methylene blue or angiotensin II only as specialist rescue.
- 7
Order
WeanWean noradrenaline (or adrenaline) first; stop vasopressin when noradrenaline is low (e.g. < 0.1 mcg/kg/min).
First-line vasopressor
Noradrenaline (norepinephrine)
- Dose
- 0.05-0.5 mcg/kg/min
- Range
- 0.01–1 mcg/kg/min
- Preparation
- 4 mg in 50 mL NS/D5 = 80 mcg/mL
- Target
- MAP 65 mmHg (60-65 if septic and aged ≥ 65)
- Worked example
- 70 kg × 0.1 mcg/kg/min = 7 mcg/min × 60 = 420 mcg/h ÷ 80 mcg/mL = 5.25 mL/h
Second vasopressor
Vasopressin
- Dose
- 0.03 units/min fixed
- Preparation
- 20 units in 50 mL = 0.4 units/mL
- Worked example
- 0.03 units/min × 60 = 1.8 units/h ÷ 0.4 = 4.5 mL/h
Third agent or with cardiac dysfunction
Adrenaline (epinephrine)
- Dose
- 0.05-0.3 mcg/kg/min
- Preparation
- 4 mg in 50 mL = 80 mcg/mL
- Worked example
- 70 kg × 0.05 = 3.5 mcg/min = 210 mcg/h ÷ 80 = 2.6 mL/h
Bolus for transient vasodilatation or LVOT obstruction
Phenylephrine
- Dose
- 50-100 mcg
- Preparation
- 10 mg in 100 mL NS = 100 mcg/mL; 0.5-1 mL per bolus
Vasoactive drugs at a glance
| Drug | Receptors | Main effect | Best use | Watch for |
|---|---|---|---|---|
| Noradrenaline | α1 +++, β1 + | Vasoconstriction, modest inotropy | First-line in most shock | Ischaemia, extravasation |
| Vasopressin | V1 | Vasoconstriction, catecholamine-sparing | Second agent in vasodilatory shock; RV failure | Digital/mesenteric ischaemia |
| Adrenaline | β1 +++, β2 ++, α1 ++ | Inotropy + vasoconstriction | Refractory shock, anaphylaxis | Lactate rise, tachyarrhythmia |
| Phenylephrine | α1 | Pure vasoconstriction | Anaesthesia, LVOT obstruction, AF with hypotension | Reflex bradycardia, ↓ CO |
| Dopamine | DA, β1, α1 (dose-dependent) | Inotropy, chronotropy | Rarely: bradycardia without pacing | Arrhythmias; worse in cardiogenic shock |
| Dobutamine | β1 ++, β2 + | Inotropy, vasodilatation | Low output with adequate MAP | Hypotension, tachycardia |
| Milrinone | PDE-3 inhibitor | Inotropy, pulmonary and systemic vasodilatation | RV failure, high PVR, beta-blocked | Hypotension; accumulates in AKI |
Calculators for this topic
Infusion rate from mcg/kg/min
Pump rate in mL/h for drugs dosed in mcg/kg/min (noradrenaline, adrenaline, dobutamine, milrinone, nitroglycerin by weight).
Dose from pump rate (mcg/kg/min)
Reverse calculation: what dose is the patient receiving at the current pump rate?
Mean arterial pressure
(SBP + 2 × DBP) ÷ 3 (estimate; use the arterial line value when available).
References
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Vasopressor escalation
Step 1 of ~4
Noradrenaline 0.05-0.1 mcg/kg/min, titrate
Based on Prescott HC, Antonelli M, Alhazzani W, et al. Educational use; follow local protocol.
Evidence
- SSC 2026: noradrenaline first line over dopamine, adrenaline or selepressin (strong) and over vasopressin or angiotensin II (now conditional); add vasopressin on escalating noradrenaline doses (conditional, moderate certainty); add adrenaline if MAP stays low on both (conditional); start vasopressors peripherally rather than delay (conditional); MAP 65 mmHg kept within ~5 mmHg (strong), 60-65 mmHg if aged ≥ 65 (new, conditional). New: suggests against terlipressin and against beta-blockers to treat septic shock; insufficient evidence for methylene blue.
- VASSPR (2026): in ~3,960 septic shock patients, starting vasopressin at 0.1 vs 0.4 mcg/kg/min noradrenaline-equivalent did not change 28-day mortality (31.8% vs 33.0%).
- SOAP II (2010): dopamine vs noradrenaline had similar overall mortality but more arrhythmias, and worse outcome in cardiogenic shock.
- VASST (2008): vasopressin added to noradrenaline did not reduce mortality overall; possible benefit in less severe shock.
- SEPSISPAM (2014): MAP 80-85 vs 65-70 had no mortality difference; less RRT in chronic hypertensives, more AF.
- 65 trial (2020): permissive MAP 60-65 in ≥ 65-year-olds was non-inferior.
- ATHOS-3 (2017): angiotensin II raised MAP in catecholamine-refractory vasodilatory shock; no proven mortality benefit.
Controversies
- Timing of vasopressin and "early multimodal vasopressors".
- Methylene blue in refractory vasoplegia: small trials only.
🇮🇳 India notes
- Angiotensin II is not marketed in India; methylene blue is cheap and available but evidence is limited (verify local protocol).
- Terlipressin is sometimes used instead of vasopressin; it is longer acting and not interchangeable, and SSC 2026 suggests against it in septic shock.
References
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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.