{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T23:11:14Z","timestamp":1790377874317,"version":"4.1.0"},"reference-count":50,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2026,6,12]],"date-time":"2026-06-12T00:00:00Z","timestamp":1781222400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>The case for early vasopressor initiation in septic shock has been argued in detail in physiologic reviews and randomized trials. The evidence base is no longer the limiting factor. What remains limiting is delivery. Across most U.S. emergency departments and many international settings, patients with septic shock still do not reliably receive norepinephrine within the first hour of recognition. This review reframes the early-vasopressor question from a physiologic argument into an implementation problem and identifies three structural barriers that operate independently of any individual clinician\u2019s understanding of the underlying evidence. The first is regulatory: the SEP-1 quality measure, despite a documented physician exception for the fluid requirement, continues to incentivize a fluids-first sequence as the institutional default. The second is cultural: the gap between policies that permit peripheral norepinephrine administration and the workflows, scope-of-practice arrangements, and standing orders required to actually start it at the bedside. The third is upstream: time-to-vasopressor is partly a downstream surrogate for time-to-recognition, and interventions that target only the pressor decision miss the larger source of delay. We propose a parallel resuscitation framework with explicit protocolized triggers and stratify implementation considerations across U.S. academic centers, U.S. community emergency departments, and resource-limited international settings. Closing the gap means stopping the physiology argument and rebuilding the operational architecture.<\/jats:p>","DOI":"10.3390\/jcm15124572","type":"journal-article","created":{"date-parts":[[2026,6,15]],"date-time":"2026-06-15T08:57:58Z","timestamp":1781513878000},"page":"4572","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["The Implementation Gap in Early Septic Shock Resuscitation: A Three-Barrier Framework"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-4143-5673","authenticated-orcid":false,"given":"Sajid","family":"Kadir","sequence":"first","affiliation":[{"name":"Divisions of Cardiovascular Medicine and Pulmonary and Critical Care Medicine, University of Florida College of Medicine\u2014Jacksonville, Jacksonville, FL 32209, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8985-7518","authenticated-orcid":false,"given":"Travis","family":"Murphy","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of Miami, Miami, FL 33136, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph","family":"Shiber","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Florida College of Medicine\u2014Jacksonville, Jacksonville, FL 32209, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"200","DOI":"10.1016\/S0140-6736(19)32989-7","article-title":"Global, Regional, and National Sepsis Incidence and Mortality, 1990\u20132017: Analysis for the Global Burden of Disease Study","volume":"395","author":"Rudd","year":"2020","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"239","DOI":"10.1186\/s13054-020-02950-2","article-title":"Mortality in Sepsis and Septic Shock in Europe, North America and Australia between 2009 and 2019\u2014Results from a Systematic Review and Meta-Analysis","volume":"24","author":"Bauer","year":"2020","journal-title":"Crit. 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