A 65-year-old post-operative patient in the ICU develops vasodilatory shock with warm peripheries, high cardiac output, and low SVR following laparotomy for perforated bowel. Norepinephrine is titrated to 0.5 mcg/kg/min. According to current SCCM SURVIVE SEPSIS guidelines (2021), which adjunctive vasopressor should be added NEXT to reduce norepinephrine requirements?
- A Vasopressin 0.03–0.04 units/min ✓
- B Phenylephrine
- C Epinephrine
- D Dopamine
Explanation
Surviving Sepsis Campaign 2021 guidelines recommend adding vasopressin (0.03–0.04 units/min) as the second vasopressor in septic shock when norepinephrine doses reach 0.25–0.5 mcg/kg/min, either to achieve target MAP or to allow norepinephrine dose reduction. Vasopressin acts on V1 receptors in vascular smooth muscle independent of adrenergic pathways, providing synergistic vasoconstriction. The VASST trial and meta-analyses support its use. Epinephrine is a third-line agent; phenylephrine is not recommended due to reflex bradycardia; dopamine is not recommended due to increased arrhythmia rates.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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