Norepinephrine in Septic Shock: Five Reasons to Initiate it Early

Septic shock is one of the main causes of admission and death in critically ill patients [1]. Septic shock is characterized by a combination of hypovolemia, peripheral vascular dysfunction resulting in hypotension and abnormalities in the local/ regional distribution of blood flow, cardiac failure and cell dysfunction. Importantly, the hemodynamic profile differs from patient to patient. In some septic patients, hypovolemia is predominant. In others, a marked decrease in vascular tone or myocardial depression is in the forefront of the hemodynamic failure. A variety of combinations can thus exist. In addition to macrocirculatory disorders, microcirculatory abnormalities contribute to tissue hypoxia through altered oxygen extraction. Whatever the macro- and microcirculatory disturbances, the prognosis of septic shock is tightly linked to how soon antibiotic therapy and hemodynamic management are initiated, including administration of fluid and of vasopressors to target a mean arterial pressure (MAP) > 65mmHg [1]. Currently, the early use of vasopressors is one of the emerging concepts in the hemodynamic management of septic shock that may change our practice. In this chapter, we will set out five reasons to support early initiation of vasopressors, and namely, of norepinephrine (Box 1).