Refractory septic shock — escalation viva

This is refractory septic shock. Despite adequate fluid and a vasopressor to the target mean arterial pressure, the lactate is rising, the patient is oliguric, and she is developing respiratory and neurological failure. The resuscitation is not working, and the question is why, and what to do next.^[2]

^[2]The first step is to question the assumptions of the resuscitation. Is the source controlled? A biliary source with a rising lactate demands an urgent search for and relief of an obstruction or a collection — an ultrasound or computed tomography and early biliary drainage — because an undrained focus defeats any amount of resuscitation. Is the antibiotic appropriate and at the right dose? The culture results and the source dictate a review and, where needed, broadening. Is the volume truly adequate, or is she under-filled or, conversely, overloaded — a focused cardiac ultrasound distinguishes a hyperdynamic, under-filled, or failing pump.

The escalation is to critical care. She is intubated and ventilated for her respiratory failure and to reduce the work of breathing, with lung-protective settings. Invasive monitoring guides the vasopressors and the fluids. ADRENAL: 90-day death 27.9% vs 28.8% (OR 0.95) with hydrocortisone 200 mg/day; faster shock reversal.^[1] SSC 2021 suggests IV corticosteroids when vasopressors are ongoing, and adding vasopressin (usually 0.03 units/min) instead of escalating norepinephrine once the dose is 0.25–0.5 μg/kg/min.^[2] Track lactate and organ failure.^[3]