2/1/2024 0 Comments Systemic shockIn this viewpoint article we describe a pragmatic, multi-faceted approach to managing patients with refractory septic shock. Microcirculatory failure and associated ischaemic consequences are frequently observed and alternative therapeutic strategies are desperately needed to improve outcomes in this small subgroup of critically ill patients. Furthermore, patients with vasopressor requirements greater than 1 μg/kg/min norepinephrine or equivalent who continue to deteriorate clinically have a reported mortality as high as 80–90%. Regardless of the precise definition, there is an associated mortality of up to 60%. Refractory septic shock is variably defined as the presence of hypotension, with end-organ dysfunction, requiring high-dose vasopressor support often greater than 0.5 μg/kg/min norepinephrine or equivalent. As a result, there is little conclusive evidence to guide management in this particular population. This subgroup of patients is often poorly represented in large randomised controlled trials investigating the efficacy of interventions in septic shock. However, a small proportion of patients fail to respond to these measures and deteriorate precipitously into refractory shock and progressive multi-organ failure. Appropriate and timely antimicrobial therapy, source control if indicated, fluid therapy, and targeted vasopressors remain the backbone of treatment. The Surviving Sepsis Guidelines provide a suitable framework to guide therapy for the majority of patients with septic shock.
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