In a perioperative patient with septic shock after initial fluid resuscitation, which vasopressor is recommended as first-line therapy?

• A. Norepinephrine
• B. Epinephrine
• C. Phenylephrine
• D. Dopamine

Answer: (A)

In septic shock after fluids, the goal is to restore mean arterial pressure and perfusion by using a vasopressor. Norepinephrine is preferred because it provides strong alpha-1–mediated vasoconstriction to raise systemic vascular resistance and arterial pressure, while offering some beta-1 activity to support cardiac output without causing widespread tachycardia. This balance improves organ perfusion, including the kidneys, and is associated with better outcomes in septic shock.

Other agents either increase afterload without enough cardiac output support or carry higher risks. Phenylephrine is a pure alpha-1 agonist that can markedly increase afterload and reduce cardiac output. Epinephrine can cause significant tachycardia, increased myocardial oxygen demand, and lactate production, which may complicate management. Dopamine has a higher risk of tachyarrhythmias and can be less favorable overall. Start norepinephrine and titrate to achieve a target MAP around 65 mmHg, using supportive strategies as needed.