The norepinephrine dosing dilemma in septic shock: a narrative review

PURPOSE: The Surviving Sepsis Campaign (SSC) guidelines recommend norepinephrine to achieve a mean arterial pressure (MAP) target of ≥65 mmHg. While norepinephrine counteracts decreased vascularresistance and improves tissue perfusion, high doses may induce excessivevasoconstriction, compromising perfusion and leading to organ failure. Thisreview examines whether microcirculatory resuscitation should be prioritizedover macrocirculatory MAP targets in norepinephrine therapy. METHODS: A narrative review was conductedusing PubMed, Scopus, and Science Direct (2009-2025). We included clinicalstudies and reviews on adults with septic shock, focusing on norepinephrinedosing and its effects on MAP and tissue perfusion. RESULTS: Evidence suggests that a fixed MAP target of ≥65 mmHg may not universally optimize outcomes, as tissue perfusion does not consistently correlate with MAP. Advanced monitoring of microcirculation helps correct microcirculatory stagnant hypoxia and tissue perfusion. Achieving the minimum required tissue perfusion through perfusion-guided monitoring allows physicians and nurses to determine the optimal norepinephrine dosage and ideal MAP for each patient, based on their clinical condition and medical history. CONCLUSION: Consequently, optimizing microcirculation using bedside monitoring technologies may replace the rigid MAP target of ≥65 mmHg. Integration of microcirculatory monitoring into clinical practice represents a paradigm shift toward personalized hemodynamic management.