Subset of sepsis with circulatory and cellular/metabolic dysfunction: persisting hypotension requiring vasopressors plus lactate >2 mmol/L despite adequate fluid resuscitation.
⚠ Red flags
- Lactate >4 after resuscitation — refractory shock
- LVEF <30% on echo — cardiogenic component
- Anuric AKI — early RRT
- DIC — coagulopathy with bleeding/thrombosis
Diagnostic criteria
Clinical
- Sepsis with persistent hypotension despite adequate fluids
- Need for vasopressors to maintain MAP ≥65 mmHg
Investigations
- Lactate >2 mmol/L despite resuscitation
Scoring tools
- SOFA / qSOFA
- APACHE II at ICU admission
Investigations
Essential
- Lactate (serial)
- Blood cultures ×2 before antibiotics
- FBC, CRP, procalcitonin, U&E, LFTs, coagulation, ABG
- Source workup: CXR, urinalysis, focused imaging
Optional
- Echo / focused cardiac ultrasound for cardiac dysfunction
- Cortisol if relative adrenal insufficiency suspected
Management
Acute
- Hour-1 sepsis bundle (see Sepsis guideline)
- Crystalloid 30 mL/kg within first 3h (reassess responsiveness with PLR/PPV)
- Noradrenaline first-line vasopressor; titrate to MAP ≥65
- Add vasopressin 0.03 units/min if noradrenaline >0.25 µg/kg/min
- Hydrocortisone 200 mg/day IV if refractory shock
- Dobutamine if myocardial dysfunction documented on echo
Long-term
- De-escalate antibiotics by 48–72h based on cultures
- Early rehabilitation when haemodynamically stable
Non-pharmacological
- Source control (drain, debridement, line removal)
- DVT and stress ulcer prophylaxis
- Glycaemic control 7.8–10 mmol/L
Pharmacological
| Drug | Dose | Notes |
|---|---|---|
| Noradrenaline | 0.05–3 µg/kg/min IV | First-line vasopressor. |
| Vasopressin | 0.03 units/min IV (fixed) | Add when noradrenaline >0.25 µg/kg/min — catecholamine-sparing. |
| Hydrocortisone | 50 mg IV QDS or 200 mg/day infusion | Refractory shock on high-dose vasopressors. |
| Adrenaline | 0.05–1 µg/kg/min IV | Third-line vasopressor or if cardiac dysfunction. |
| Dobutamine | 2.5–20 µg/kg/min IV | For documented low cardiac output (echo-guided). |
Monitoring
- Continuous arterial line BP, MAP target ≥65
- Lactate clearance — aim ≥10% per 2h
- Hourly urine output ≥0.5 mL/kg/h
- Repeat echo if persistent shock
Referral criteria
- ICU admission required — all septic shock
- ECMO centre if profound cardiogenic-septic component
Complications
- Multi-organ dysfunction syndrome
- Limb ischaemia from high-dose vasopressors
- ICU-acquired weakness
- Post-sepsis cognitive and functional decline
Special populations
- Pregnancy
- Maintain MAP and uteroplacental perfusion; left lateral tilt; obstetrics involvement early.
- Renal impairment
- Adjust antibiotic dosing; consider early RRT for refractory acidosis or fluid overload.
- Hepatic impairment
- Vasopressors may worsen splanchnic perfusion; balance against shock control.
- Elderly
- Pre-existing frailty informs ICU decisions; lower physiological reserve.
- Paediatric
- Use weight-based bolus 10–20 mL/kg, reassess; epinephrine may be preferred first-line.