Septic shock requiring vasopressors — FFICM MCQ

Correct answer: D — Start noradrenaline aiming for MAP about 65 mmHg

The correct answer is D, start noradrenaline aiming for MAP about 65 mmHg. This woman has septic shock (fluid-refractory hypotension, MAP 55 mmHg, lactate 4.6 mmol/L, oliguria) with a vasoplegic picture (warm peripheries, bounding pulses), indicating the deficit is vasomotor tone rather than intravascular volume. UK critical care and NICE-aligned guidance recommend noradrenaline as the first-line vasopressor once initial fluid resuscitation has failed to restore perfusion, titrated to an initial MAP target of about 65 mmHg. Noradrenaline's alpha-1 mediated vasoconstriction restores systemic vascular resistance and perfusion pressure with less tachyarrhythmia risk than alternative agents, and evidence shows no mortality benefit from higher MAP targets while harm increases with excess catecholamine dosing. Why the other options are wrong: B. Dopamine as first-line vasopressor: Dopamine causes more tachyarrhythmias and worse outcomes than noradrenaline in septic shock, so it is not used first-line. A. Repeated fluid boluses until lactate normalises: She has already received an adequate 30 ml/kg crystalloid load and remains hypotensive with a vasodilated picture; further unguided fluid risks pulmonary oedema without correcting the loss of vascular tone, and lactate alone should not drive further boluses. E. Dobutamine as sole vasoactive drug: Dobutamine is an inotrope reserved for sepsis-associated cardiac dysfunction with persistent hypoperfusion despite adequate fluids and vasopressor, not a substitute for a vasopressor in a warm, vasoplegic patient. C. Aim for MAP above 90 mmHg routinely: Higher MAP targets do not improve survival and increase arrhythmia and vasopressor-related harm; targets are only raised individually, for example with chronic hypertension, not routinely. Key point: In fluid-refractory septic shock with warm, vasoplegic hypotension, start noradrenaline promptly and titrate to a MAP of about 65 mmHg rather than giving further fluid or using dopamine, dobutamine, or higher MAP targets.

Reference: NICE Guideline NG51 (updated as NG253), Suspected sepsis: recognition, diagnosis and early management, section on management of septic shock and vasopressor use, nice.org.uk/guidance/ng51