Vasopressors in Septic Shock

Severe sepsis and septic shock are complications of infection leading to high morbidity and mortality. Hemodynamic outcomes are considered surrogate markers for survival- an ultimate goal of treatment strategies. The goal of vasoactive agents is to improve arterial blood pressure (age related norms) without associated adverse effects. Early initiation of a vasoactive agent in fluid-refractory septic shock has a significant role in the outcome; initiation within an hour of presentation is recommended and is associated with favorable outcomes. The choice of the correct vasoactive agent in a given scenario has a pivotal role on the desired outcome as well as the duration to achieve it. Cardiac dysfunction is a well recognized complication of septic shock, occurring in about 60% of the patients. So ionotropes may play a role in septic shock patients with associated myocardial dysfunction and signs of organ hypoperfusion despite achieving adequate preload and mean arterial pressure. In children presentation of septic shock is more complex, predominantly vasoconstricted with low cardiac output. Sometimes they can have deranged myocardial contractility and SVR problems requiring combination of inotropes and vasopressors. Hence the choice of inotrope remains empirical. Vasoactive therapy should be guided by clinical end points.