A 60-year-old man is in the surgical ICU with refractory septic shock on mechanical ventilation despite 4 litres of crystalloid resuscitation. Noradrenaline infusion has been titrated to 0.5 mcg/kg/min. Blood pressure remains 75/45 mmHg. Lactate is rising at 6.2 mmol/L. According to current Surviving Sepsis Campaign guidelines, what is the most appropriate next step?

• A Add intravenous vasopressin up to 0.03 units per minute ✓
• B Start intravenous dobutamine 5 mcg/kg/min
• C Add intravenous hydrocortisone 200 mg per day
• D Switch to intravenous adrenaline as first-line vasopressor

Explanation

Surviving Sepsis Campaign 2021 recommends adding vasopressin up to 0.03 units per minute to noradrenaline when MAP target is not achieved, to reduce noradrenaline dose rather than escalating catecholamines. Adrenaline is an alternative second-line agent. Dobutamine is considered when myocardial dysfunction with persistent hypoperfusion is present. Steroids are considered if fluids and vasopressors are insufficient.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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