What is the next step for a patient with unrecordable blood pressure and non-palpable pulse, currently on full dose of Noradrenaline (norepinephrine) and Dopamine and Vasopressin, without access to mechanical circulatory support like Intra-Aortic Balloon Pump (IABP), Extracorporeal Membrane Oxygenation (ECMO), Impella, or TandemHeart?

Management of Profound Shock Refractory to Multiple Vasopressors

In a patient with non-recordable blood pressure and non-palpable pulse despite maximum doses of norepinephrine, dopamine, and vasopressin, the next step should be administration of high-dose epinephrine (0.05-0.5 μg/kg/min) while simultaneously correcting any underlying metabolic derangements and considering corticosteroid administration.

Immediate Interventions

1. Add Epinephrine to Current Vasopressor Regimen

• Start epinephrine infusion at 0.05 μg/kg/min and rapidly titrate up to 0.5 μg/kg/min as needed 1
• Epinephrine has both potent alpha and beta effects that can improve cerebral and myocardial blood flow by increasing peripheral vasoconstriction 2
• Continue current vasopressors while adding epinephrine to maximize vasopressor effect

2. Correct Metabolic Derangements

• Check and correct hypoglycemia and hypocalcemia immediately 3
• Consider sodium bicarbonate administration (1-2 mEq/kg IV bolus) if severe metabolic acidosis is present, especially with pH < 7.2 3
• Monitor serum electrolytes, especially potassium, as severe acidosis may cause hyperkalemia

3. Consider Corticosteroid Administration

• Administer hydrocortisone 200-300 mg/day if escalating vasopressor doses are required 1
• Particularly important in patients with suspected relative adrenal insufficiency

Secondary Interventions

4. Optimize Fluid Status

• Despite being on multiple vasopressors, ensure adequate preload with additional fluid challenges if no signs of volume overload 1
• Administer 20 mL/kg boluses of isotonic crystalloid while monitoring for signs of improvement or fluid overload 1

5. Identify and Treat Reversible Causes

• Rule out and correct:
  • Pericardial effusion/tamponade
  • Tension pneumothorax
  • Elevated intra-abdominal pressure (>12 mmHg)
  • Profound hypoxemia
  • Severe acidosis
  • Electrolyte abnormalities (especially hyperkalemia, hypocalcemia)
  • Toxin ingestion requiring specific antidotes

6. Consider Additional Inotropic Support

• Add dobutamine (2-20 μg/kg/min) if evidence suggests myocardial depression 3
• Consider milrinone (0.375-0.75 μg/kg/min) especially if patient is on beta-blockers 3
• Levosimendan (0.1 μg/kg/min) may be considered if available 3

Advanced Considerations

7. Empiric Antibiotic Coverage

• If septic shock is suspected, ensure broad-spectrum antibiotics have been administered within the first hour 3
• Consider clindamycin if toxic shock syndrome is suspected 3

8. Aggressive Source Control

• If infection is the suspected cause, ensure aggressive source control with drainage or debridement as needed 3

9. Transfer Considerations

• Arrange immediate transfer to a facility with mechanical circulatory support capabilities if patient remains in refractory shock despite above measures

Special Situations

Beta-Blocker or Calcium Channel Blocker Overdose

• For beta-blocker toxicity: Consider glucagon (5-10 mg IV bolus followed by 1-5 mg/hour infusion) 3
• For calcium channel blocker toxicity: Consider calcium chloride (20 mg/kg of 10% solution) 3
• Consider high-dose insulin therapy in either scenario 3

Cocaine-Induced Shock

• Consider nitroglycerin and benzodiazepines 3
• Avoid beta-blockers 3

Monitoring During Resuscitation

• Continuous ECG monitoring for arrhythmias
• Arterial line for continuous blood pressure monitoring if possible
• Frequent assessment of:
  • Mental status
  • Skin perfusion
  • Urine output
  • Lactate levels
  • Arterial blood gases
  • Electrolytes

Pitfalls to Avoid

• Delaying epinephrine administration in profound shock
• Failing to identify and treat reversible causes
• Neglecting metabolic derangements (acidosis, hypocalcemia, hypoglycemia)
• Continuing to escalate vasopressors without addressing underlying cause
• Overlooking relative adrenal insufficiency in refractory shock

Remember that the combination of dobutamine and norepinephrine has been shown to be superior to vasopressin in experimental cardiogenic shock by better restoring ventriculoarterial matching 4. If the patient remains in profound shock despite all these measures, the prognosis is extremely poor without access to mechanical circulatory support.