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Refractory Shock Management

Refractory Shock Management: Refractory Shock (Adults) → Reassess the Cause: Bleeding, Obstruction, Heart, Toxins → Is Sepsis a Cause of the Shock? → Se...

Pathway Overview

20 steps

Algorithm Steps

20 total

  1. 01Start

    Refractory Shock (Adults)

    MAP below target despite fluid and a rising noradrenaline dose. Adults only: not for children.

  2. 02Warning

    Reassess the Cause: Bleeding, Obstruction, Heart, Toxins

    These causes need specific treatment. More vasopressor alone will fail. Pregnant or postpartum: call obstetrics; displace the uterus to the left; think of haemorrhage, amniotic fluid embolism, peripartum cardiomyopathy.

    • Bedside echo now: tamponade, dilated RV (PE), poor LV, LVOT obstruction, empty ventricle (bleeding)
    • Also exclude tension pneumothorax, anaphylaxis, adrenal crisis, beta-blocker or CCB overdose
    • Check the arterial line trace and that the vasopressor infusions reach the patient
  3. 03Decision

    Is Sepsis a Cause of the Shock?

    Yes if sepsis is a cause, also in mixed shock. No if another cause explains the shock.

  4. If Yes
    1. 04Decision

      Septic: Source Still Not Controlled?

      Look again for a source that needs drainage, debridement or device removal

    2. If Yes
      1. 05Action

        Source Not Controlled: Urgent Source Control

        Ideally within 6 h of diagnosis (SSC 2026)

        • Drain abscess or empyema
        • Debride infected or necrotic tissue
        • Remove a possibly infected line or device once other access is in place
        • Surgery or interventional radiology as needed
      2. 06Action

        Septic: Optimise Current Therapy

        Adults only. Do this before adding a third agent. Mixed shock: also treat the other cause now (bleeding, obstruction, heart).

        • MAP target 65 mmHg; 60-65 mmHg if aged 65 or more
        • Noradrenaline dose rising: add vasopressin 0.03 units/min, fixed dose, not titrated (SSC 2021: usually at noradrenaline 0.25-0.5 mcg/kg/min)
        • Review antimicrobials: right drug, dose and cover for resistant organisms
        • Fluid only if fluid responsive on a dynamic test; avoid overload
        • Sodium bicarbonate only if pH 7.2 or less with AKI stage 2-3; not to raise BP
      3. 07Decision

        Septic: Hydrocortisone Not Yet Started?

        SSC 2026 suggests IV corticosteroids in septic shock

      4. If Yes
        1. 08Action

          Not on Steroids: Start IV Hydrocortisone

          Strongyloides risk (endemic area, including remote northern Australia): send serology and ask ID about ivermectin. Do not delay hydrocortisone.

          • Adult: hydrocortisone 50 mg IV every 6 h, or 200 mg/day by continuous infusion
          • SSC 2021 threshold: noradrenaline or adrenaline 0.25 mcg/kg/min or more for at least 4 h
          • Fludrocortisone may be added (SSC 2026). Dose: see SSC 2026
          • No high-dose short courses (more than 400 mg/day for less than 3 days): SCCM 2024 recommends against
          • Usual duration 5-7 days (trial regimens)
        2. 09Decision

          Still Below MAP Target or Poorly Perfused?

          Check MAP, lactate, capillary refill and urine output

        3. If Yes
          1. 10Decision

            Echo: Heart Function Adequate (Normal or High Output)?

            Repeat bedside echo before a third agent: LV, RV, filling, valves, tamponade, LVOT gradient

          2. If Yes
            1. 11Warning

              Before Adrenaline: Exclude LVOT Obstruction or Takotsubo

              Adrenaline and other catecholamine inotropes worsen these and can cause collapse.

              • Echo: hyperdynamic LV with systolic anterior motion or an LVOT gradient, or Takotsubo pattern
              • If present: no adrenaline, no dobutamine; stop any inotrope
              • Instead: fluid if fluid responsive, a vasoconstrictor without inotropic effect (vasopressin or phenylephrine), urgent cardiology and ICU consultant advice
            2. 12Action

              Normal or High Output: Add Adrenaline

              Third agent for low MAP on noradrenaline and vasopressin (SSC 2026). Not in dynamic LVOT obstruction or Takotsubo. Tachyarrhythmia: adrenaline can worsen it; ask the ICU consultant.

              • Adult adrenaline infusion 0.05-2 mcg/kg/min, titrate to MAP (1 mg/mL ampoules; dilute by local protocol)
              • No vasopressin available: add adrenaline to noradrenaline
              • Adrenaline raises lactate; use other signs of perfusion too
              • Methylene blue: no SSC recommendation; specialist decision only. Serotonin syndrome risk with SSRIs, SNRIs, MAOIs or opioids; not in G6PD deficiency
              • Terlipressin: SSC suggests against. Angiotensin II: not TGA-registered
            3. 13Decision

              Still Refractory After These Steps?

              MAP below target or perfusion getting worse

            4. If Yes
              1. 14Decision

                Severe Heart Failure with Low Output: MCS Candidate?

                Mechanical support helps only when the heart is failing, not in vasoplegia with normal output

              2. If Yes
                1. 15Action

                  MCS Candidate: Call the Shock Team or ECMO Centre Now

                  Refer early; retrieval and transfer take time

                  • Temporary MCS: not recommended in unselected MI-related cardiogenic shock (ESC 2026)
                  • STEMI shock with LV failure and no risk of hypoxic brain injury: microaxial flow pump should be considered (see cardiogenic shock pathway)
                  • Septic cardiomyopathy with very low output: VA-ECMO only in expert centres
                  • Routine IABP: not recommended
                2. 16Warning

                  ⚠️ Goals of Care: Discuss Early

                  For every patient with persistent refractory shock

                  • Mortality is high: discuss likely outcomes and the limits of treatment with the patient or family
                  • Involve the senior ICU clinician; involve palliative care early
                  • Record the agreed ceiling of treatment
                3. 17Outcome

                  Persistent Shock: Follow the Agreed Plan

                  Repeat the echo and the search for causes: bleeding, tamponade, abdominal compartment syndrome, adrenal insufficiency, low ionised calcium, infusion faults. Keep treating reversible causes. If none remains and treatment cannot meet the patient's goals, change to comfort-focused care.

                If No
                1. Path rejoins step 16Shared downstream outcome
              If No
              1. 18Outcome

                Shock Resolving: Wean Support

                Wean vasopressors gradually and keep MAP at target. Keep treating the cause and reassess often.

            If No
            1. 19Action

              Low Output: Add an Inotrope to the Vasopressor

              Hypoperfusion despite adequate fluid and MAP. First exclude dynamic LVOT obstruction and Takotsubo on echo: catecholamine inotropes make them worse; get cardiology advice.

              • Add dobutamine to noradrenaline, or add adrenaline instead of dobutamine (SSC 2026)
              • Adult dobutamine: start 0.5-1 mcg/kg/min; titrate, usually 2-20 mcg/kg/min; usual maximum 20 mcg/kg/min
              • Keep the vasopressor: the inotrope is added, not a substitute
              • Dobutamine can worsen hypotension and cause tachyarrhythmia
              • Milrinone: specialist use; it causes vasodilation
              • Levosimendan: SSC suggests against; not TGA-registered
            2. Path rejoins step 13Shared downstream outcome
          If No
          1. Path rejoins step 18Shared downstream outcome
        If No
        1. Path rejoins step 09Shared downstream outcome
      If No
      1. Path rejoins step 06Shared downstream outcome
    If No
    1. 20Action

      Not Septic: Treat the Specific Cause

      Treat the cause now. If still shocked after that, go to the MAP and perfusion check (evidence is mainly from septic shock).

      • Bleeding: blood products and urgent bleeding control (surgery or interventional radiology)
      • Tamponade: urgent drainage. Tension pneumothorax: decompress
      • Massive PE: reperfusion (see PE pathway)
      • Cardiogenic: see cardiogenic shock pathway; call the Shock Team
      • Anaphylaxis: IV adrenaline infusion (see anaphylaxis pathway)
      • Adrenal crisis: IV hydrocortisone now; do not wait for the cortisol result
      • Beta-blocker or CCB overdose: call Poisons Information Centre 13 11 26
      • Low ionised calcium: replace
      • Vasodilatory shock with a rising noradrenaline dose: consider adding vasopressin before a third agent; ICU consultant (evidence mainly from septic shock)
    2. Path rejoins step 09Shared downstream outcome

Guideline Source

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026

DOI: 10.1097/CCM.0000000000007075View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Evidence is mainly from septic shock. In other shock types, treat the cause first and use the cause-specific pathway.
  • Refractory shock has no single definition. Noradrenaline thresholds vary and depend on whether the dose is stated as base or tartrate salt.
  • Rescue therapies (adrenaline as third agent, methylene blue, mechanical support) have little RCT evidence.
  • Mechanical circulatory support is available only in some tertiary centres.

Contraindicated Populations

pediatric

Applicable Regions

USEUGlobalAU

AU: Vasopressin is registered as argipressin 20 units/mL. Angiotensin II and levosimendan are not on the ARTG. Australian noradrenaline ampoules state the dose as base (1 mg/mL). Poisons Information Centre 13 11 26.

Global: Surviving Sepsis Campaign 2026 adult guidelines (SCCM/ESICM); ESC 2026 heart failure guideline for mechanical support.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Refractory Shock Management?

The Refractory Shock Management is a emergency clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026.

What guideline is the Refractory Shock Management based on?

This algorithm is based on Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (DOI: 10.1097/CCM.0000000000007075).

What are the limitations of the Refractory Shock Management?

Known limitations include: Evidence is mainly from septic shock. In other shock types, treat the cause first and use the cause-specific pathway.; Refractory shock has no single definition. Noradrenaline thresholds vary and depend on whether the dose is stated as base or tartrate salt.; Rescue therapies (adrenaline as third agent, methylene blue, mechanical support) have little RCT evidence.; Mechanical circulatory support is available only in some tertiary centres.. Individual patient factors may require deviation from these recommendations.

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