Refractory Shock Management

Algorithm Steps

1. ▶

   Start

   Refractory Shock

   Persistent hypotension despite NE >0.5 mcg/kg/min + vasopressin

   1. ●

      Action

      Reassess Diagnosis & Etiology

      Ensure correct shock type identified

      • Septic: Source control adequate?
      • Cardiogenic: Echo - LV function?
      • Hypovolemic: Ongoing bleeding?
      • Obstructive: Tamponade, PE, tension PTX?
      • Mixed: Multiple contributing factors?
      1. ◆

         Decision

         Source Control Achieved? (If Septic)

         Critical for septic shock resolution

         1. ●

            Action

            Urgent Source Control

            Within 6-12h of identification

            • Drainage of abscess/empyema
            • Debridement of infected tissue
            • Line/device removal
            • Surgical intervention if needed
            1. ●

               Action

               Optimize Current Therapy

               Before adding rescue therapies

               • Adequate volume status (avoid overload)
               • Antibiotics appropriate for source
               • Vasopressin at 0.03-0.04 units/min
               • Norepinephrine maximally titrated
               • Corticosteroids if not started
               1. ◆

                  Decision

                  On Corticosteroids?

                  Hydrocortisone for vasopressor-dependent shock

                  1. ●

                     Action

                     Add Hydrocortisone

                     If not already started

                     • Hydrocortisone 200mg/day
                     • 50mg IV q6h or continuous
                     • Duration 5-7 days
                     • May reduce time on vasopressors
                     1. ●

                        Action

                        Add Third Vasopressor

                        Epinephrine or phenylephrine

                        • Epinephrine: 0.01-0.1 mcg/kg/min
                        • - Inotropic + vasopressor
                        • - Note: increases lactate
                        • Phenylephrine: 0.5-5 mcg/kg/min
                        • - Pure alpha, if tachycardia limiting
                        • Angiotensin II: 20-40 ng/kg/min (if available)
                        1. ◆

                           Decision

                           Cardiac Function Assessment

                           Echo to guide further therapy

                           • LV systolic function
                           • RV function
                           • Filling pressures
                           • Valvular pathology
                           1. ●

                              Action

                              Add Inotrope for LV Dysfunction

                              If cardiac output is low

                              • Dobutamine 2.5-20 mcg/kg/min
                              • - May worsen hypotension
                              • Milrinone (if dobutamine intolerant)
                              • - Greater vasodilation
                              • Levosimendan (where available)
                              1. ◆

                                 Decision

                                 Mechanical Circulatory Support?

                                 For appropriate candidates

                                 1. ●

                                    Action

                                    Mechanical Support Options

                                    If available and appropriate candidate

                                    • VA-ECMO: Severe cardiogenic + respiratory
                                    • Impella: LV unloading
                                    • IABP: Limited role, less common
                                    • Consider early referral to ECMO center
                                    1. ✓

                                       Outcome

                                       Shock Improving

                                       Wean vasopressors, continue monitoring

                                    2. ✓

                                       Outcome

                                       Refractory Despite Maximal Therapy

                                       Comfort-focused care if no reversible cause

                                 2. ⚠

                                    Warning

                                    ⚠️ Goals of Care Discussion

                                    Essential in refractory shock

                                    • Mortality high despite maximal therapy
                                    • Early palliative care involvement
                                    • Family communication
                                    • Avoid futile interventions