In sepsis management, when should vasopressors be started after fluid resuscitation?

• A. MAP ≥ 65 mmHg after fluids; continue fluids.
• B. MAP < 65 mmHg after fluids; start vasopressors.
• C. MAP > 90 after fluids; start vasopressors.
• D. MAP < 50; start vasopressors immediately.

Answer: (B)

In septic shock, you first give a fluid bolus to restore circulating volume, then you aim to achieve a perfusion target pressure. The key moment to add vasopressors is when, after that adequate fluid resuscitation, the mean arterial pressure remains below the target (about 65 mmHg). At that point, vasopressor therapy is started to constrict vessels and improve organ blood flow, rather than pushing fluids further with diminishing returns and risk of overload. This approach keeps perfusion pressure up without relying on increasingly large fluid volumes. If the MAP is already at or above the target after fluids, vasopressors aren’t needed. In practice, norepinephrine is the typical first-line agent when vasopressors are indicated.