How can I manage a patient with septic shock, hypotension, and acute respiratory distress syndrome (ARDS) on maximal doses of noradrenaline (norepinephrine), dopamine, and vasopressin, with evidence of fluid overload on ultrasound?

Management of Refractory Septic Shock with ARDS and Evidence of Fluid Overload

In a patient with septic shock and ARDS on maximal vasopressor therapy with evidence of fluid overload, adding IV hydrocortisone (200-300 mg/day) should be your next intervention to improve blood pressure, followed by consideration of angiotensin II if no improvement occurs. 1

Assessment of Current Status

The patient presents with:

• Septic shock with hypotension (BP 90/60)
• ARDS
• On maximum doses of noradrenaline, dopamine, and vasopressin
• Evidence of fluid overload:
  • Non-collapsing IVC (1.3 cm)
  • B-lines on lung ultrasound
  • Very low urine output

Step 1: Optimize Current Vasopressor Therapy

Before adding additional agents:

• Ensure norepinephrine is being administered appropriately (0.05-1.0 μg/kg/min) 1
• Confirm vasopressin is at the maximum recommended dose (0.03 U/min) 1
• Consider discontinuing dopamine, as it is not recommended as a first-line agent in septic shock and increases risk of tachyarrhythmias 1, 2

Step 2: Add Corticosteroids

• Initiate IV hydrocortisone 200-300 mg/day (divided doses or continuous infusion)
• Hydrocortisone is recommended when escalating vasopressor doses are required, particularly in patients with suspected relative adrenal insufficiency 1
• This can improve vasopressor responsiveness and potentially allow reduction in vasopressor doses

Step 3: Consider Additional Vasopressor Options

If blood pressure remains inadequate after corticosteroids:

• Consider adding angiotensin II (starting at 0.5 μg/kg/min, titrating up to 6 μg/kg/min) 3, 4

  • Angiotensin II works through a different pathway than catecholamines and vasopressin
  • May be useful for rapid resuscitation of profoundly hypotensive patients 5

• Consider epinephrine as an additional agent (0.05-0.5 μg/kg/min) 1, 2

  • Recommended when an additional agent is needed to maintain adequate blood pressure
  • Has both vasopressor and inotropic effects

Step 4: Address Fluid Status and Respiratory Support

Given the evidence of fluid overload:

• Avoid additional fluid administration
• Consider initiating continuous renal replacement therapy (CRRT) if available, which can help:
  • Remove excess fluid
  • Improve acid-base balance
  • Remove inflammatory mediators
• Optimize ventilator settings for ARDS (lung-protective ventilation)

Step 5: Ongoing Monitoring

Monitor the following parameters closely:

• Blood pressure
• Heart rate
• Urine output
• Skin perfusion
• Mental status
• Lactate clearance
• Renal and liver function tests 1

Important Caveats

• Avoid phenylephrine in septic shock except in specific circumstances 1
• Monitor for myocardial dysfunction - consider adding dobutamine (2.5-20 μg/kg/min) if there is evidence of cardiac dysfunction despite adequate blood pressure 1
• Correct acidosis if present, as it may reduce the effectiveness of vasopressors 3
• Be cautious with excessive vasoconstriction which may lead to organ ischemia/infarction 5
• Recognize that norepinephrine doses above 1 μg/kg/min are associated with mortality rates over 80%, highlighting the need for adjunctive therapies 4

Pitfalls to Avoid

• Continuing to administer fluids despite evidence of fluid overload
• Relying solely on increasing doses of the same vasopressors without adding adjunctive therapies
• Failing to address the underlying cause of septic shock (source control)
• Delaying the addition of corticosteroids in refractory shock
• Using dopamine as a primary vasopressor in septic shock 1, 2