Editing Sepsis (section)

=== Vasopressors ===
If the person has been sufficiently fluid resuscitated but the [[mean arterial pressure]] is not greater than 65&nbsp;mmHg, [[vasopressor]]s are recommended.<ref name= "SSC–G2016"/> [[Norepinephrine (medication)|Norepinephrine]] (noradrenaline) is recommended as the initial choice.<ref name= "SSC–G2016"/> Delaying initiation of vasopressor therapy during septic shock is associated with increased mortality.<ref>{{cite journal | vauthors = Bai X, Yu W, Ji W, Lin Z, Tan S, Duan K, Dong Y, Xu L, Li N | display-authors = 6 | title = Early versus delayed administration of norepinephrine in patients with septic shock | journal = Critical Care | volume = 18 | issue = 5 | pages = 532 | date = October 2014 | pmid = 25277635 | pmc = 4194405 | doi = 10.1186/s13054-014-0532-y | doi-access = free }}</ref>

Norepinephrine is often used as a first-line treatment for hypotensive septic shock because evidence shows that there is a relative deficiency of vasopressin when shock continues for 24 to 48 hours.<ref name=Avni2015/> Norepinephrine raises blood pressure through a vasoconstriction effect, with little effect on [[stroke volume]] and heart rate.<ref name="SSC–G2016"/> In some people, the required dose of vasopressor needed to increase the mean arterial pressure can become exceedingly high and it becomes toxic.<ref name=Hamzaoui2017/> To reduce the required dose of vasopressor, epinephrine may be added.<ref name=Hamzaoui2017/> Epinephrine is not often used as a first-line treatment for hypotensive shock because it reduces blood flow to the abdominal organs and increases lactate levels.<ref name= Avni2015/> Vasopressin can be used in septic shock because studies have shown that there is a relative deficiency of vasopressin when shock continues for 24 to 48 hours. However, vasopressin reduces blood flow to the heart, fingers/toes, and abdominal organs, resulting in a lack of oxygen supply to these tissues.<ref name= "SSC–G2016"/> [[Dopamine]] is typically not recommended. Although dopamine is useful for increasing the stroke volume of the heart, it causes more [[Heart arrhythmia|abnormal heart rhythms]] than norepinephrine and also has an immunosuppressive effect. Dopamine is not proven to have protective properties on the kidneys.<ref name="SSC–G2016"/> [[Dobutamine]] can also be used in hypotensive septic shock to increase cardiac output and correct blood flow to the tissues.<ref name=Dubin2017/> Dobutamine is not used as often as epinephrine due to its associated side effects, which include reducing blood flow to the gut.<ref name=Dubin2017/> Additionally, dobutamine increases the cardiac output by abnormally increasing the heart rate.<ref name=Dubin2017/>