Sepsis — FFICM MCQ

Correct answer: B — ≥65 mm Hg

The correct answer is B, MAP of at least 65 mm Hg. This patient has septic shock (hypotension persisting despite 30 mL/kg crystalloid), which is the indication for starting norepinephrine as first line vasopressor. Current international guidance, which underpins UK critical care practice, recommends targeting a MAP of 65 mm Hg once vasopressors are required in the initial resuscitation of septic shock. This threshold balances adequate organ perfusion pressure against the harms of excessive vasopressor exposure, and randomised trial evidence shows no mortality benefit from targeting higher pressures in unselected patients. The 65 mm Hg target is a starting point that should then be individualised (for example upward in patients with chronic hypertension or downward permissively in selected elderly patients) rather than fixed rigidly for every case. Why the other options are wrong: E: norepinephrine started, target MAP: this restates the intervention rather than giving a numerical target, so it does not answer the question of what MAP to aim for. A: MAP ≥50 mm Hg: this is below the threshold associated with preserved cerebral and renal autoregulation and is not supported by trial evidence as an adequate resuscitation target in septic shock. D: MAP ≥90 mm Hg for all: higher fixed targets increase vasopressor dose and duration without improving survival, and in the 65 to 85 mm Hg comparison trials no mortality benefit was seen from the higher target group overall. C: no MAP target: septic shock management requires an explicit haemodynamic endpoint to guide titration of vasopressor therapy; abandoning a target risks under or over resuscitation and delayed recognition of deterioration. Key point: once vasopressors are needed in septic shock, titrate norepinephrine to an initial MAP target of at least 65 mm Hg, adjusting individually thereafter.

Reference: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021, Evans L et al, Critical Care Medicine 2021 (PMC8486643): recommends targeting MAP 65 mm Hg in initial resuscitation of septic shock requiring vasopressors, https://pmc.ncbi.nlm.nih.gov/articles/PMC8486643/