Vasopressors and inotropes in sepsis

Sazetak

Sepsis is defined as a dysregulated host response to infection, while septic shock is a consequence of severe sepsis, followed by hypotension that is not reversed with fluid resuscitation. These life-threatening conditions require urgent treatment and remain one of the leading causes of death worldwide. Hypovolemia and low systemic vascular resistance are significant risk factors for mortality in sepsis and septic shock. One of the goals of the global initiative to improve prognosis among patients with septic shock, the Surviving Sepsis Campaign (SSC), is the maintenance of mean arterial pressure (MAP) above 65 mmHg. Achieving this value and ensuring adequate tissue perfusion require significant amounts of resuscitation fluid. Although the debate on the preferred type of fluid continues, recent studies suggest against using hydroxyethyl starches, as their use is associated with poor prognosis, and advocate for crystalloids as the fluid of choice. Patients in whom target MAP values cannot be achieved with fluids alone are candidates for vasopressor or inotrope therapy. Norepinephrine (a potent α-adrenergic agonist with moderate β-adrenergic effects) is the first-line vasopressor therapy, with the benefit of improving blood flow to the splanchnic circulation and a lower incidence of arrhythmias. Epinephrine is recommended as second-line therapy and can be used alone or in combination with norepinephrine. Phenylephrine (a pure α-agonist) should not be used alone as it may decrease stroke volume, except as a salvage therapy combined with other vasopressors or inotropes. Vasopressin is recommended in combination with norepinephrine, but not as a monotherapy. Dopamine is not recommended for renal protection and should only be used in highly selected cases. Dobutamine remains the drug of choice for patients with myocardial dysfunction and signs of inadequate tissue perfusion, even after achieving adequate MAP.