A 60-year-old woman in septic shock is on norepinephrine titrated to 0.4 micrograms/kg/min yet maintains MAP of only 58 mmHg. Per Surviving Sepsis Campaign guidance, which is the recommended next agent?
- A High-dose dopamine infusion
- B Vasopressin 0.03 units/min added to norepinephrine ✓
- C Methylene blue bolus
- D Switch entirely to phenylephrine
Correct answer: B. Vasopressin 0.03 units/min added to norepinephrine
Explanation
When norepinephrine requirements exceed roughly 0.25 to 0.5 micrograms/kg/min, fixed-dose vasopressin at 0.03 units/min is added as a catecholamine-sparing agent, per the VASST trial and current guidance. Dopamine increases arrhythmia risk and is no longer favoured, phenylephrine lacks beta activity and may reduce cardiac output, and methylene blue is reserved for refractory vasoplegia outside routine protocols.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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