A 55-year-old woman with septic shock is started on norepinephrine at 0.3 mcg/kg/min. MAP remains 58 mmHg. According to Surviving Sepsis Campaign 2021 guidelines, what is the recommended next step in vasopressor management?
- A Switch to epinephrine as the primary vasopressor
- B Add vasopressin up to 0.03 units/minute as a second-line agent ✓
- C Add dobutamine for inotropic support
- D Increase norepinephrine to 1.0 mcg/kg/min before adding any second agent
Correct answer: B. Add vasopressin up to 0.03 units/minute as a second-line agent
Explanation
The Surviving Sepsis Campaign 2021 recommends adding vasopressin (up to 0.03 U/min) as a second-line vasopressor to norepinephrine to raise MAP or to decrease norepinephrine dosage. The VASST trial showed benefit of adding vasopressin at 0.01-0.03 U/min. Epinephrine is an alternative second-line agent. Dobutamine is added for persistent hypoperfusion despite adequate MAP, not for refractory hypotension alone.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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