Management of Refractory Septic Shock

Initial Management

The American College of Critical Care Medicine recommends administering at least 30 mL/kg of IV crystalloid fluid within the first 3 hours of resuscitation, using balanced solutions or normal saline as first-choice fluids, for patients with septic shock 2
The Society of Critical Care Medicine suggests continuing fluid administration using a challenge technique as long as hemodynamic parameters improve, with dynamic measures of fluid responsiveness preferred over static measures, in patients with septic shock 2
The Infectious Diseases Society of America recommends administering broad-spectrum antimicrobials within the first hour of recognition of septic shock, after obtaining appropriate cultures if this doesn't significantly delay therapy, for patients with septic shock 2
The Society of Critical Care Medicine advises identifying and implementing source control interventions as rapidly as possible, ideally within 12 hours of diagnosis, for patients with septic shock 2

The Society of Critical Care Medicine recommends initiating norepinephrine as the first-choice vasopressor if the patient remains hypotensive despite adequate fluid resuscitation, targeting a mean arterial pressure of 65 mmHg, for patients with septic shock 3
The American College of Critical Care Medicine suggests adding vasopressin (0.01-0.04 units/min) to norepinephrine when an additional agent is needed to maintain adequate blood pressure or to decrease norepinephrine dosage, for patients with septic shock 3, 4
The Society of Critical Care Medicine recommends avoiding dopamine except in highly selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia, for patients with septic shock 3
The American College of Critical Care Medicine advises using phenylephrine only in specific circumstances: when norepinephrine causes serious arrhythmias, when cardiac output is known to be high with persistently low blood pressure, or as salvage therapy, for patients with septic shock 3

The Society of Critical Care Medicine recommends administering hydrocortisone 200-300 mg/day for at least 5 days, followed by a tapering dose, for patients with refractory shock 4
The American College of Critical Care Medicine suggests evaluating for and reversing pneumothorax, pericardial tamponade, or endocrine emergencies in patients with refractory shock 5
The Extracorporeal Life Support Organization recommends considering ECMO for refractory septic shock, particularly in pediatric patients, with a strength of evidence rated as moderate 6

The Pediatric Critical Care Medicine society recommends beginning peripheral inotropic support until central venous access can be attained in children who are not responsive to fluid resuscitation, for pediatric patients with septic shock 6
The American Academy of Pediatrics suggests adding vasodilator therapies to inotropes for children with low cardiac output and elevated systemic vascular resistance with normal blood pressure, for pediatric patients with septic shock 6
The Society of Critical Care Medicine recommends considering phosphodiesterase III inhibitors in pediatric cases with low cardiac output and normal arterial pressure, for pediatric patients with septic shock 4

The Society of Critical Care Medicine advises reassessing hemodynamic status frequently through clinical examination and available physiologic variables, for patients with septic shock 2
The American College of Critical Care Medicine recommends guiding resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion, for patients with septic shock 2
The Society of Critical Care Medicine suggests monitoring for signs of fluid overload, including hepatomegaly and rales, especially in pediatric patients, for patients with septic shock 5

The Society of Critical Care Medicine recommends avoiding fluid overresuscitation as it can delay organ recovery, prolong ICU stay, and increase mortality, for patients with septic shock 2
The American College of Critical Care Medicine advises recognizing that the standard approach may need modification based on individual patient characteristics, particularly cardiac function, for patients with septic shock 2