Shock States in Critically Ill Adults

Classification and Diagnosis

The Society of Critical Care Medicine defines septic shock as persistent hypotension (MAP <65 mmHg or SBP <90 mmHg) despite adequate fluid resuscitation (at least 30 mL/kg of crystalloids) in the presence of documented or suspected infection 1, 2
The American College of Critical Care Medicine recommends using a diastolic blood pressure ≤40 mmHg or diastolic shock index ≥3 as a critical diagnostic threshold for septic shock 4
Critical diagnostic thresholds for septic shock include SBP <90 mmHg or reduction ≥40 mmHg from baseline, MAP <65 mmHg despite initial fluid resuscitation of 30 mL/kg crystalloids, heart rate ≥90 bpm with signs of tissue hypoperfusion, lactate ≥1 mmol/L, oliguria ≤0.5 mL/kg/h for at least 2 hours despite adequate fluids, altered mental status, confusion, or apathy, and reduced capillary refill or skin mottling indicating peripheral vasoconstriction 1, 2

The Surviving Sepsis Campaign recommends norepinephrine as the first-choice vasopressor, targeting MAP ≥65 mmHg, in septic shock patients 5, 6, 7, 2
The Society of Critical Care Medicine suggests adding vasopressin 0.03 units/min when norepinephrine requirements are moderate-to-high in septic shock patients 6, 7
The American College of Critical Care Medicine recommends hydrocortisone 200 mg/day when hemodynamic stability cannot be achieved with fluids and vasopressors in septic shock patients 5, 7, 2
Inotropic support (dobutamine) is recommended for persistent hypoperfusion with low cardiac output in cardiogenic shock patients 5, 7

The Society of Critical Care Medicine advises against delaying vasopressor initiation in septic shock patients with profound hypotension (diastolic BP ≤40 mmHg) while waiting for additional fluid boluses 7
The American College of Critical Care Medicine recommends against continuing aggressive fluid resuscitation when CVP is already elevated (≥13 mmHg), as this risks pulmonary edema without improving perfusion 7
The Surviving Sepsis Campaign advises against using dopamine as first-line therapy in septic shock; reserve only for highly selected patients with bradycardia and low arrhythmia risk 5, 6, 7
The Society of Critical Care Medicine recommends against abruptly stopping hydrocortisone once started, as this can cause hemodynamic deterioration and rebound inflammation 2