A patient with septic shock remains hypotensive despite escalating norepinephrine to 0.4 microgram/kg/min. Vasopressin is being considered as an add-on agent. The accepted practice regarding its use is:

• A High-dose vasopressin 0.1 units/min titrated to MAP
• B Fixed low-dose vasopressin 0.03 units/min added to reduce catecholamine requirement ✓
• C Vasopressin as the sole first-line vasopressor before norepinephrine
• D Vasopressin is contraindicated in any patient requiring more than 0.2 microgram/kg/min of norepinephrine

Explanation

Guidelines recommend adding fixed low-dose vasopressin, typically 0.03 units/min, when norepinephrine requirements climb toward 0.25 to 0.5 microgram/kg/min, to spare catecholamine dose and restore vascular tone via V1 receptors. High-dose titrated vasopressin causes splanchnic and digital ischaemia, which is why the VASST trial used the fixed low dose. Vasopressin is never first-line, and it is specifically indicated, not contraindicated, in catecholamine-refractory shock.

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

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