According to current international guidelines for septic shock, which vasopressor should be used as the first-line agent?

• A Dopamine
• B Phenylephrine
• C Epinephrine
• D Norepinephrine ✓

Explanation

Norepinephrine is the first-line vasopressor in septic shock because it is a potent alpha agonist that raises SVR with modest beta-1 chronotropic effect. Dopamine causes more tachyarrhythmias, and the SOAP II trial showed higher arrhythmia rates compared with norepinephrine. Epinephrine causes transient lactate rise and tachycardia. Phenylephrine, a pure alpha agonist, may reduce stroke volume in patients with impaired cardiac function and is reserved for specific situations such as norepinephrine-induced arrhythmia.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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