SEPTIC SHOCK - WHEN TO ADD A 2ND PRESSOR? VASST Trial:

Added: 2026-05-20

[00:00:00]When should you add a second vasopressor? In 2008, the New England Journal of Medicine put out a trial called the VAS trial where they looked at patients with septic shock who were on low-dose norepinephrine and they either just kept giving them more and more norepinephrine or they added vasopressin as a second agent. Now, they were looking to see if there was any difference in mortality at 28 days and in the end they concluded there wasn't any based on their statistical calculation. They looked at around 800 patients. If you look a little closer though, you'll see that there was definitely trends towards but less mortality and better outcomes in the patients that got vasopressin. Maybe not statistically significant, but definitely the numbers were there.

[00:00:39]I like using vasopressin pretty early in septic shock as a second agent to norepinephrine predominantly because it works through a different way than the norepinephrine does and you get to avoid the side effects that you see when you're on really high doses of norepinephrine where that heart rate just keeps pumping up faster and faster.

[00:00:56]You have really bad perfusion to the gut and to the kidneys and a little bit more renal injury. The one thing with vasopressin you got to be careful of is digital ischemia. So, you got to make sure that that IV is a good IV, ideally a central venous catheter.

[00:01:10]We'll talk another time about when you should do peripheral IV vasopressors and when you should do central venous IV pressors, but that's my take on when you should add vasopressin onto norepinephrine. Surviving Sepsis guidelines say you can add it as soon as your norepinephrine gets to about 0.25 mics per kilo per minute. So, don't forget your vaso.