Alarmed

🧠 Vasopressors in Septic Shock: Are we still treating numbers instead of patients? A new review in Intensive Care Medicine challenges how we think about vasopressor therapy in septic shock. 🧐The uncomfortable truth We often believe vasopressor management is straightforward: ➡️ Start norepinephrine ➡️ Add vasopressin if needed ➡️ Escalate to reach MAP targets But reality is far more complex. ⚠️ What the paper clearly highlights 1️⃣ Norepinephrine is first-line—but not “one-size-fits-all” Strongest evidence base ✔️ BUT: massive interindividual variability Same dose ≠ same biological effect 👉 Dose escalation may reflect non-responsiveness, not underdosing 2️⃣ Vasopressin: logical, but not proven Added to reduce catecholamine exposure No consistent mortality benefit Possible signal if used early at lower NE doses 👉 We are likely using it too late and too blindly 3️⃣ Angiotensin II: physiologically appealing, clinically uncertain Improves MAP Reduces NE requirements No clear outcome benefit 👉 Probably works… but only in selected phenotypes 4️⃣ Hydrocortisone: underrated tool Reduces vasopressor requirements Likely improves vascular sensitivity 👉 Not just “adjunct”, but essential 🚨 The real paradigm shift This is the most important message: 👉 We are still practicing dose-based vasopressor therapy 👉 Instead of mechanism-based, personalized resuscitation 🧬 Why trials keep being “negative” Not because therapies don’t work. But because: We treat heterogeneous populations Without identifying: Adrenergic responsiveness Vasopressin deficiency RAAS dysfunction 👉 Wrong drug for the wrong patient = neutral trial 🔮 Where we are heading The future is clear: ✔️ Bedside assessment of vascular responsiveness ✔️ Functional hemodynamic phenotyping ✔️ Biomarker-guided vasopressor selection ✔️ Moving from MAP targets → perfusion physiology 🫀 Clinical take-home Start norepinephrine early ✔️ Reassess mechanism before escalating❗ Add vasopressin early, not late Consider hydrocortisone when NE escalates Minimize sedation → reduces vasoplegia 💬 My reflection We mastered how to push vasopressors. Now we need to master when, why, and in whom. 👉 The next leap in septic shock care will not be a new drug. 👉 It will be better patient selection. 📃Intensive Care Med doi.org/10.1007/s00134-026-0…