What is the first-line vasopressor for septic shock and what MAP target is typically aimed for?

• A. Norepinephrine; MAP ≥65 mmHg.
• B. Epinephrine; MAP ≥70 mmHg.
• C. Dopamine; MAP ≥60 mmHg.
• D. Phenylephrine; MAP ≥65 mmHg.

Answer: (A)

In septic shock, the immediate goal is to restore arterial pressure and ensure adequate organ perfusion after fluid resuscitation. Norepinephrine is the first-line vasopressor because it provides strong alpha-adrenergic vasoconstriction to raise systemic vascular resistance, which elevates mean arterial pressure, while adding only modest beta-1 activity to support cardiac output. This balance makes it the most effective and safest initial choice among vasopressors for septic shock. Other agents can be used, but they’re not preferred as the starting option: epinephrine can cause more tachycardia and metabolic effects; dopamine carries a higher risk of arrhythmias and adverse outcomes; phenylephrine is a pure vasoconstrictor with no inotropic support, and is generally not first-line in this context.

The typical MAP target is at least 65 mmHg to ensure adequate perfusion of vital organs. Some patients, especially those with chronic hypertension or specific cardiovascular or neurologic conditions, may require a higher target, but 65 mmHg serves as the standard starting goal. If hypotension persists despite reaching this MAP with norepinephrine, additional vasopressors or adjunctive therapies are considered based on perfusion markers and clinical response.