**4. Vasopressors in septic shock management**

Vasopressor increases systemic vascular resistance (SVR), cardiac output CO, and heart rate (HR) and rapidly restore organ perfusion [71]. Vasopressors either catecholamine- or non-catecholamine-based agents. Dopamine, norepinephrine, epinephrine, and phenylephrine are catecholamine-based vasopressors while vasopressin is a non-catecholamine-based vasopressors [72]. Norepinephrine is the first-line vasopressor for patients with septic shock [20]. Early vasopressors administration in septic shock patients revert the severely impaired arterial tone and associated with lowest mortality rate occurred when vasoactive agents were started 1 to 6 hours of septic shock identification [20, 73–76]. CENSER trial shows early NE administration is associated with increased shock control over the first 6 hours [76]. Addition of vasopressin to norepinephrine in the few hours of shock when doses of norepinephrine dose is ≥1 μg/Kg/min, may decrease mortality, arrhythmia, hypotension and need for renal replacement therapy [77, 78]. Addition of vasopressin to norepinephrine is more effective in early septic shock management and reach MAP target faster and lower incidence of atrial fibrillation [79, 80]. Possible complication of vasopressor includes dysrhythmias tachycardia or atrial fibrillation. Hyperlactatemia and hyperglycemia [80, 81]. Peripheral administration of vasopressors includes extravasation and peripheral ischemia given their potent vasoconstrictive properties [82]. Extravasation was uncommon if vasopressors are administered peripherally for less than 22 hours. Peripheral administration of vasopressors in upper arm using 20 gauge or larger is safe and feasible in the initial hours of resuscitation [82–84]. Vasopressor treatment can be initiated on a peripheral venous line with non-invasive BP monitoring, and shifted, as soon as possible, to central venous catheter with arterial pressure monitoring [85].

Early norepinephrine administration should be started in septic shock patient with slow response to fluid resuscitation. Vasopressin is recommended in when norepinephrine dose is ≥1 μg/Kg/min.

## **5. Conclusion**

Septic shock is life threatening condition complicated with hypoperfusion, Indices of hypoperfusion are combinations of pressure and flow measurements and clinical markers. Indices should be taken together and not to rely only on one index to diagnose and mange hypoperfusion. Perfusion indices should be used to individualize fluid administration approach in balanced crystalloid is recommended over normal slain in septic shock resuscitation. Early norepinephrine administration should be started in septic shock patient with slow response to fluid resuscitation. Vasopressin is recommended in when norepinephrine dose is ≥1 μg/Kg/min.

*Assessment and Management of Hypoperfusion in Sepsis and Septic Shock DOI: http://dx.doi.org/10.5772/intechopen.98876*
