Optimal norepinephrine-equivalent dose to initiate epinephrine in patients with septic shock

The specific norepinephrine dose at which epinephrine should be added in septic shock is unclear. This study sought to determine the norepinephrine-equivalent dose at epinephrine initiation that correlated with hemodynamic stability. Septic shock patients receiving both norepinephrine and epinephrine were included in this study. Classification and regression tree analysis was conducted to determine breakpoints in norepinephrine-equivalent dose predicting hemodynamic stability, with two cohorts identified. The primary outcome was hemodynamic stability, and secondary outcomes were shock-free survival, time to achieve hemodynamic stability, and change in SOFA score. Optimal dose group was identified as initiating epinephrine when norepinephrine-equivalent dose was between 37 and 133 μg/min. A total of 138 and 61 patients were classified in optimal and non-optimal dose groups, respectively. Baseline characteristics were similar between groups except vasopressin use was more frequent in the optimal dose group. More patients in optimal dose group versus non-optimal dose group achieved hemodynamic stability (40 [29%] vs. 9 [14.8%]), absolute risk difference 14.2% [95% CI 2.5–25.9%]; p = .03). On multivariable analysis, initiating epinephrine within the optimal norepinephrine-equivalent dose range was independently associated with higher odds of hemodynamic response (OR 3.06 [95% CI 1.2–7.6]; p = .02). No differences were observed in other secondary outcomes. Initiation of epinephrine when patients were receiving norepinephrine-equivalent doses of 37–133 μg/min was associated with a higher rate of hemodynamic stability. •Norepinephrine-equivalent dose at epinephrine initiation that correlated with hemodynamic stability was evaluated.•Initiation of epinephrine at norepinephrine-equivalent doses of 37–133 μg/min was associated with hemodynamic stability.•No differences were observed in shock-free survival, change in SOFA, ICU-free days, lactic acidosis, and new-onset arrhythmias.•The incidence of hemodynamic stability after epinephrine initiation was low.