{"id":3203,"date":"2026-09-09T08:21:52","date_gmt":"2026-09-09T16:21:52","guid":{"rendered":"https:\/\/www.nicolekupchikconsulting.com\/news\/?p=3203"},"modified":"2026-09-09T08:21:54","modified_gmt":"2026-09-09T16:21:54","slug":"when-do-you-add-a-second-vasopressor-in-sepsis","status":"publish","type":"post","link":"https:\/\/www.nicolekupchikconsulting.com\/news\/when-do-you-add-a-second-vasopressor-in-sepsis\/","title":{"rendered":"When do You Add a Second Vasopressor in Sepsis?"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">As ICU nurses, many of you have taken care of sick, septic patients.\u00a0\u00a0 When do you add a second pressor?\u00a0 Let\u2019s review the guidelines as we follow a patient scenario.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">3-Hour Treatment Bundle for Sepsis:<\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Measure lactate level<\/li>\n\n\n\n<li>Obtain blood cultures prior to antibiotics \u2013 but DON\u2019T DELAY<\/li>\n\n\n\n<li>Administer antibiotics within 1 hour<\/li>\n\n\n\n<li>Administer 30 mL\/kg of crystalloid for hypotension or lactate \u2265 4 mmol\/L<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">An 73-year-old patient is admitted to the ICU with urosepsis.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">VS: HR 120 in sinus tachycardia, BP 85\/50 (62) mm Hg, RR 24, 93% SpO<sub>2<\/sub> on room air<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Pertinent labs: WBC 12 mm<sup>3<\/sup>, lactate 5 mmol\/L<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">In the first hour the nurses in the ED have drawn blood cultures and started broad spectrum antibiotics.&nbsp;&nbsp; To keep the patient\u2019s MAP &gt; 65 mm Hg, the patient received the standard rapid fluid resuscitation of 30 mL\/kg of lactated ringers.&nbsp; However, the patient is <strong>still hypotensive.&nbsp;<\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Let\u2019s look at the Critical Care 6-hour Treatment Bundle for Sepsis:<\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Apply vasopressors for hypotension that does not respond to fluid resuscitation (immediately!)<\/li>\n\n\n\n<li>Maintain MAP \u2265 65 mm Hg<ul><li>1<sup>st<\/sup> line vasopressor: Norepinephrine<\/li><\/ul>\n<ul class=\"wp-block-list\">\n<li>2<sup>nd<\/sup> line vasopressor: Vasopressin or Epinephrine<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Consider invasive arterial blood pressure monitoring<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Repeat VS after the fluid bolus: HR 115 in sinus tachycardia, BP 86\/45 (59) mm Hg, RR 24, 91% SpO<sub>2<\/sub> on 2 L NC<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The providers have ordered a norepinephrine infusion to keep the MAP &gt; 65, which is the standard vasopressor to use in septic shock. &nbsp;You are continuing to titrate up the norepinephrine, but when should you start another pressor?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">According to the Surviving Sepsis Guidelines, if you are continuing to escalate the norepinephrine, consider adding a vasopressin infusion.&nbsp; Institutional guidelines will vary when it comes to vasopressor dosing.&nbsp; In my experience, when the norepinephrine dose is approaching 15 \u2013 20 mcg\/min, we are starting the discussion of adding another vasopressor. Vasopressin is commonly used as it innervates different receptors than a catecholamine pressor.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">In this scenario, the provider has ordered a vasopressin infusion, so you start it.&nbsp; Here are the next set of vital signs 10 minutes later:<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">HR 105 ST, BP 95\/56 (69) mm Hg, RR 24, 92% SpO<sub>2<\/sub> on 2 L NC<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Your patient is doing better!&nbsp; Hooray!&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Other things to consider \u2013 keep an eye on organ perfusion through urine output, capillary refill, knee mottling, skin temperature, mentation and lactate levels.&nbsp; The goal for lactate is to normalize it by improving perfusion.&nbsp; For urine output, the goal is least 0.5 mL\/kg\/hour.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">If you administered fluid and wonder if your patient will be fluid responsive, try a Passive Leg Raise (PLR) test with a stroke volume\/cardiac output monitoring device or assess Stroke Volume Variability with an arterial line.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">September is Sepsis Awareness month!&nbsp; Early recognition is key and saves lives!<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Nicole covers all of this and more in her&nbsp; <a href=\"https:\/\/www.nicolekupchikconsulting.com\/booksAndCourses\/online-courses\/166\/surviving-sepsis\"><strong>Surviving Sepsis: When Every Second Counts<\/strong><\/a>online course which is normally $149.00 but for the month of <strong>September it is only $59.00!<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Buy it here: <a href=\"https:\/\/www.nicolekupchikconsulting.com\/booksAndCourses\/online-courses\/166\/surviving-sepsis\">Sepsis Online Course &#8211; Nicole Kupchik<\/a><\/p>\n\n\n\n<h2 class=\"wp-block-heading\">References:<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www-uptodate-com.offcampus.lib.washington.edu\/contents\/evaluation-and-management-of-suspected-sepsis-and-septic-shock-in-adults?search=septic%20shock%20treatment&amp;source=search_result&amp;selectedTitle=1~150&amp;usage_type=default&amp;display_rank=1&amp;searchCorrelationId=a8a01b87-5f66-4939-8ec9-ba9084584bfd&amp;searchCorrelationTerm=septic%20shock%20treatment\">Evaluation and management of suspected sepsis and septic shock in adults &#8211; UpToDate<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.sccm.org\/clinical-resources\/guidelines\/guidelines\/surviving-sepsis-campaign-international-guidelines-for-management-of-sepsis-and-septic-shock-2026\">Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 | SCCM<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.uptodate.com\/contents\/evaluation-and-management-of-suspected-sepsis-and-septic-shock-in-adults\">Evaluation and management of suspected sepsis and septic shock in adults &#8211; UpToDate<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>As ICU nurses, many of you have taken care of sick, septic patients.\u00a0\u00a0 When do you add a second pressor?\u00a0 Let\u2019s review the guidelines as we follow a patient scenario. 3-Hour Treatment Bundle for Sepsis: An 73-year-old patient is admitted to the ICU with urosepsis.&nbsp; VS: HR 120 in sinus tachycardia, BP 85\/50 (62) mm [&hellip;]<\/p>\n","protected":false},"author":11,"featured_media":3001,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[46],"tags":[],"ppma_author":[62],"class_list":["post-3203","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-nurse-education"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\r\n<title>When do You Add a Second Vasopressor in Sepsis? 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