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Critical CareEmergency

Refractory Shock Management

Refractory Shock Management: Refractory Shock → Reassess Diagnosis & Etiology → Source Control Achieved? (If Septic) → Urgent Source Control → Optimize ...

Pathway Overview

15 steps

Algorithm Steps

15 total

  1. 01Start

    Refractory Shock

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

  2. 02Action

    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?
  3. 03Decision

    Source Control Achieved? (If Septic)

    Critical for septic shock resolution

  4. 04Action

    Urgent Source Control

    Within 6-12h of identification

    • Drainage of abscess/empyema
    • Debridement of infected tissue
    • Line/device removal
    • Surgical intervention if needed
  5. 05Action

    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
  6. 06Decision

    On Corticosteroids?

    Hydrocortisone for vasopressor-dependent shock

  7. 07Action

    Add Hydrocortisone

    If not already started

    • Hydrocortisone 200mg/day
    • 50mg IV q6h or continuous
    • Duration 5-7 days
    • May reduce time on vasopressors
  8. 08Action

    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)
  9. 09Decision

    Cardiac Function Assessment

    Echo to guide further therapy

    • LV systolic function
    • RV function
    • Filling pressures
    • Valvular pathology
  10. 10Action

    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)
  11. 11Decision

    Mechanical Circulatory Support?

    For appropriate candidates

  12. 12Action

    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
  13. 13Outcome

    Shock Improving

    Wean vasopressors, continue monitoring

  14. 14Outcome

    Refractory Despite Maximal Therapy

    Comfort-focused care if no reversible cause

  15. 15Warning

    ⚠️ Goals of Care Discussion

    Essential in refractory shock

    • Mortality high despite maximal therapy
    • Early palliative care involvement
    • Family communication
    • Avoid futile interventions
  16. Path rejoins step 14Shared downstream outcome
  17. Path rejoins step 11Shared downstream outcome
  18. Path rejoins step 08Shared downstream outcome
  19. Path rejoins step 05Shared downstream outcome

Guideline Source

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021

DOI: 10.1007/s00134-021-06506-yView Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Definition of refractory varies (typically NE >0.5-1 mcg/kg/min)
  • Limited RCT data for many rescue therapies
  • Mechanical support availability varies
  • Goals of care should be addressed early
  • Underlying etiology is key

Contraindicated Populations

pediatric

Applicable Regions

USEUGlobal

Global: Based on SSC 2021 + expert consensus

Version 1Next review: 2027-01-01

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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 2021.

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 2021 (DOI: 10.1007/s00134-021-06506-y).

What are the limitations of the Refractory Shock Management?

Known limitations include: Definition of refractory varies (typically NE >0.5-1 mcg/kg/min); Limited RCT data for many rescue therapies; Mechanical support availability varies; Goals of care should be addressed early; Underlying etiology is key. Individual patient factors may require deviation from these recommendations.

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