Septic shock remains a health care concern associated with significant morbidity and mortality. The Surviving
Sepsis Campaign Guidelines for Management of
Sepsis and
Septic Shock recommend early fluid
resuscitation and antimicrobials. Beyond initial management, the guidelines do not provide clear recommendations on appropriate time to initiate vasoactive
therapies and
corticosteroids in patients who develop
shock. This review summarizes the literature regarding time of initiation of these interventions. Clinical data regarding time of initiation of these
therapies in relation to
shock onset, sequence of treatments with regard to each other, and
clinical markers evaluated to guide initiation are summarized. Early-high vasopressor initiation within first 6 h of
shock onset is associated with lower mortality. Following
norepinephrine initiation, the exact dose and timing of escalation to adjunctive
vasopressor agents are not well elucidated in the literature. However, recent data indicate that timing may be an important factor in initiating vasopressors and adjunctive
therapies, such as
corticosteroids.
Norepinephrine-equivalent dose and
lactate concentration can aid in determining when to initiate
vasopressin and
angiotensin II in patients with
septic shock. Future guidelines with clear recommendations on the time of initiation of
septic shock therapies are warranted.