Refractory septic shock and alternative wordings: A systematic review of literature

Hemodynamic effects of adjunct arginine vasopressin to norepinephrine in septic shock: insights from a prospective multicenter registry study

BACKGROUND

The Surviving Sepsis Campaign guidelines suggest adding arginine vasopressin (AVP) when norepinephrine (NE) doses reach 0.25-0.50 µg/kg/min in septic shock patients. However, relying solely on a NE threshold has limitations, as other factors may be valuable in guiding AVP therapy during septic shock. Therefore, we aimed to identify additional patient characteristics associated with AVP hemodynamic responsiveness.

METHODS

A multicenter, prospective, observational study was conducted among adult ICU patients who met the predefined criteria for septic shock (not reaching the individual target mean arterial pressure despite adequate fluid resuscitation and NE base dose > 0.25 µg/kg/min) and received AVP therapy. AVP hemodynamic responsiveness was the primary study outcome, defined as stabilization or decrease of NE infusion rate two hours after initiating AVP. Secondary outcomes included shock duration and rebound hypotension following termination of AVP infusion. Univariate and multivariable regression analyses were performed to detect associations between characteristics and outcomes.

RESULTS

Between May 2020 and October 2023, 200 septic shock patients originating from 11 different ICUs were included. Of these, 153 (79%) met the definition for AVP hemodynamic responsiveness. Obesity and hyperlactatemia was negatively associated with AVP-response (adjusted Odds Ratio [aOR] 0.30, 95%CI 0.14-0.65 and aOR 0.86, 95%CI 0.75-0.99, respectively), while a NE infusion rate ≥ 0.30 µg/kg/min showed positive odds of AVP response (aOR 2.33, 95%CI 1.06-5.14). Incidence of new-onset atrial fibrillation was lower in AVP responders than non-responders (4% vs. 14%, p = 0.013). Higher body mass index (BMI) , NE infusion rate and duration prior to AVP initiation was associated with longer shock duration (aOR 1.06, 95%CI 1.02-1.11, aOR 1.12, 95%CI 1.01-1.25, and 1.01 95% CI 1.00-1.03, respectively), while higher pH associated with lower likelihood of prolonged shock (aOR 0.80, 95%CI 0.64-0.99). Rebound hypotension occurred in 9% when AVP was terminated, and AVP duration > 24 h was negatively associated with rebound hypotension (OR 0.22, 95%CI 0.05-0.85).

CONCLUSIONS

Arterial lactate, pH, BMI, and NE duration and dose were associated with AVP responsiveness and shock duration during septic shock, and rebound hypotension occurred in 9% during recovery. Our findings suggest that beyond NE thresholds, specific factors could be considered to optimize adjunctive AVP therapy in septic shock patients.

Early high-dose vasopressors in refractory septic shock: A cohort study

PURPOSE

Septic shock refractory to high-dose vasopressors confers unacceptably high mortality, however, the impact of timing of peak vasopressor dose exposure on outcomes is unknown.

METHODS

This retrospective cohort study included adults who required a vasopressor dose ≥0.5 μg/kg/min norepinephrine-equivalents in the first 24 h of septic shock. We used the median time to peak vasopressor dose to stratify patients into 'early' and 'late' groups. Multivariable Cox proportional hazards regression was used to assess the impact of time to peak vasopressor exposure on mortality.

RESULTS

The median time to peak vasopressor dose exposure was 6 (3,13) hours, defining the early (n = 351) and late (n = 351) groups. In the severity-adjusted multivariable analysis, the early group was less likely to die within 28 days (HR 0.76, 95 % CI 0.58-0.99). The early group experienced significantly more days alive and free from renal replacement therapy, vasopressors, mechanical ventilation, and quicker independence from vasopressors (HR 1.40, 95 % CI 1.17-1.69). Mesenteric ischemia and arrhythmias were more frequent in the late group.

CONCLUSIONS

In vasopressor-refractory septic shock, achieving the peak vasopressor dose within the first six hours of shock onset was associated with reduced mortality and more days alive and free from organ-support therapies.

Dexmedetomidine to Reduce Vasopressor Resistance in Refractory Septic Shock: α2 Agonist Dexmedetomidine for REfractory Septic Shock (ADRESS): A Double-Blind Randomized Controlled Pilot Trial

OBJECTIVES

Increasing evidence has suggested the benefits of dexmedetomidine in patients with sepsis. Dexmedetomidine may increase vasopressor sensitivity, which may be of interest in the setting of refractory septic shock. The α2 Agonist Dexmedetomidine for REfractory Septic Shock (ADRESS) pilot study aimed to evaluate the effect of dexmedetomidine on the vasopressor response in patients with refractory septic shock.

DESIGN

This study was a multicenter, randomized, placebo-controlled, double-blind pilot trial.

SETTING

The study was conducted in 5 ICUs in France.

PATIENTS

Inclusion criteria were septic shock (Sepsis-3 definition) and norepinephrine requirement greater than or equal to 0.25 µg/kg/min (0.5 µg/kg/min of norepinephrine tartrate) with persistent circulatory failure (defined by lactate > 2 mmol/L, oliguria, or skin mottling) and invasive mechanical ventilation.

INTERVENTIONS

The arterial pressure response to phenylephrine was measured before starting the treatment (0 hr), at 6 hours (primary outcome), and 12 hours. In the treatment arm, dexmedetomidine was given at a fixed dose of 1 µg/kg/hr.

MEASUREMENTS AND MAIN RESULTS

Inclusions were stopped early because of higher mortality in the dexmedetomidine arm. Thirty-two patients of the 36 planned were included. Response to phenylephrine at 6 hours was lower in the dexmedetomidine group than in the placebo group (1.26 ± 0.23 vs. 1.45 ± 0.26; p = 0.048), although this difference was also observed at baseline (p = 0.029). There were no significant differences between the groups in terms of cumulative norepinephrine dose, lactatemia, Sequential Organ Failure Assessment score, fluid balance, ventilation-free days, or occurrence of bradycardia. Mortality on day 3 was higher in the dexmedetomidine group than in the placebo group, with a difference that diminished and was no longer significant on 30 and 90 days.

CONCLUSIONS

Patients in the dexmedetomidine arm had a significantly lower response to phenylephrine at all study times including baseline, which might have contributed to higher early mortality in the dexmedetomidine arm and preclude to conclude on dexmedetomidine efficacy in refractory septic shock. However, heart rate was not decreased in the dexmedetomidine arm.

Haemodynamic management of septic shock

Septic shock is a significant challenge in the management of patients with burns and traumatic injuries when complicated by infection, necessitating prompt and effective haemodynamic support. This review provides a comprehensive overview of current strategies for vasopressor and fluid management in septic shock, with the aim to optimize patient outcomes. With regard to vasopressor management, we elaborate on the pharmacologic profiles and clinical applications of catecholamines, vasopressin derivatives, angiotensin II, and other vasoactive agents. Noradrenaline remains central to septic shock management. The addition of vasopressin, when sequentially added to noradrenaline, offers a non-catecholaminergic vasoactive effect with some clinical benefits and risks of adverse effects. Emerging agents such as angiotensin II and hydroxocobalamin are highlighted for their roles in catecholamine-resistant vasodilatory shock. Next, for fluid management, crystalloids are currently preferred for initial resuscitation, with balanced crystalloids showing benefits over saline. The application of albumin in septic shock warrants further research. High-quality evidence does not support large-volume fluid resuscitation, and an individualized strategy based on haemodynamic parameters, including lactate clearance and capillary refill time, is recommended. The existing knowledge suggests that early vasopressor initiation, particularly noradrenaline, may be critical in cases where fluid resuscitation takes inadequate effect. Management of refractory septic shock remains challenging, with novel agents like angiotensin II and methylene blue showing potential in recent studies. In conclusion, Further research is needed to optimize haemodynamic management of septic shock, particularly in developing novel vasopressor usage and fluid management approaches.

Impact of Haemoadsorption Therapy on Short Term Mortality and Vasopressor Dependency in Severe Septic Shock with Acute Kidney Injury: A Retrospective Cohort Study

Background/Objectives: Sepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection, remains a major challenge in ICUs. This study evaluated whether combining haemoadsorption therapy with continuous renal replacement therapy (CRRT) reduces ICU and short-term mortality in patients with severe septic shock and acute kidney injury (AKI) requiring CRRT. Methods: A single-centre retrospective cohort study was conducted at Rambam Health Care Campus, Haifa, Israel, from January 2018 to February 2024. Data were collected from ICU patients with severe septic shock and AKI requiring CRRT. Patients were divided into two groups: those receiving haemoadsorption therapy with CRRT and those receiving CRRT alone. Primary and secondary endpoints included ICU, 30 and 60-day mortality, vasopressor dependency index (VDI), and lactate levels. Results: Out of 545 patients with septic shock, 133 developed AKI requiring CRRT, and 76 met the inclusion criteria. The haemoadsorption group (n = 47) showed significant reductions in blood lactate levels and VDI after 24 h compared to the CRRT alone group (n = 29). ICU mortality was significantly lower in the haemoadsorption group (34.0% vs. 65.5%, p = 0.008), as was 30 and 60-day mortality (34.0% vs. 62.1%, p = 0.02, and 48.9% vs. 75.9%, p = 0.002). Multivariate analysis confirmed haemoadsorption therapy as independently associated with lower ICU and 30-day but not 60-day mortality. Conclusions: Haemoadsorption therapy combined with CRRT in patients with severe septic shock and AKI requiring CRRT is associated with improved lactate clearance, reduced vasopressor requirements, and lower ICU and 30-day mortality. Further high-quality randomized controlled trials are needed to confirm these findings.

Sepsis: key insights, future directions, and immediate goals. A review and expert opinion

This review explores the current landscape and evolving understanding of sepsis, highlighting both challenges and future directions. Sepsis remains a major global health burden, with diverse clinical presentations complicating timely diagnosis and management. Existing definitions, including the Sepsis-3 criteria, emphasize the importance of organ dysfunction, yet early sepsis detection remains limited by available tools. The Sequential Organ Failure Assessment (SOFA) score, though widely used, may not fully capture early stages of infection or account for complex presentations like noncatecholamine-resistant shock. Additionally, the review underscores the pressing need for standardized terminology across sepsis and shock characterization to ensure consistency in diagnosis and treatment strategies. Accessible, resource-adapted solutions are particularly crucial in low- and middle-income countries where sepsis-related mortality rates are higher due to limited resources. Future research should focus on developing and validating integrated, multi-parameter tools that combine clinical, biochemical, and microbiological data to improve sepsis outcomes globally. Advancing sepsis care will require both technological innovation and collaborative, globally consistent guidelines to bridge disparities in healthcare delivery.

Ten take-home messages on vasopressin use in critically ill patients

The most used vasopressors in critically ill patients are exogenous catecholamines, mainly norepinephrine. Their use can be associated with serious adverse events and even increased mortality, especially if administered at high doses. In recent years, the addition of vasopressin has been proposed to counteract the deleterious effects of high doses of catecholamines (decatecholaminization) with the intention of improving the prognosis of these patients. Currently, vasopressin has two main indications: septic shock and vasoplegic shock in the postoperative period of cardiac surgery. In septic shock, current evidence favors its early initiation before reaching high doses of norepinephrine. In the postoperative period of cardiac surgery, the different benefits of the use of vasopressin have been studied, especially in patients with atrial fibrillation and pulmonary hypertension. When used properly, vasopressin is a safe an effective drug for the indications described above.

Current perspectives in the management of sepsis and septic shock

Within patients with sepsis, there exists significant heterogeneity, and while all patients should receive conventional therapy, there are subgroups of patients who may benefit from specific therapies, often referred to as rescue therapies. Therefore, the identification of these specific patient subgroups is crucial and lays the groundwork for the application of precision medicine based on the development of targeted interventions. Over the years, efforts have been made to categorize sepsis into different subtypes based on clinical characteristics, biomarkers, or underlying mechanisms. For example, sepsis can be stratified into different phenotypes based on the predominant dysregulated host response. These phenotypes can range from hyperinflammatory states to immunosuppressive states and even mixed phenotypes. Each phenotype may require different therapeutic approaches to improve patient outcomes. Rescue strategies for septic shock may encompass various interventions, such as immunomodulatory therapies, extracorporeal support (e.g., ECMO), or therapies targeted at specific molecular or cellular pathways involved in the pathophysiology of sepsis. In recent years, there has been growing interest in precision medicine approaches to sepsis and phenotype identification. Precision medicine aims to tailor treatments to each individual patient based on their unique characteristics and disease mechanisms.

The impact of norepinephrine dose reporting heterogeneity on mortality prediction in septic shock patients

BACKGROUND

Norepinephrine (NE) is a cornerstone drug in the management of septic shock, with its dose being used clinically as a marker of disease severity and as mortality predictor. However, variations in NE dose reporting either as salt formulations or base molecule may lead to misinterpretation of mortality risks and hinder the process of care.

METHODS

We conducted a retrospective analysis of the MIMIC-IV database to assess the impact of NE dose reporting heterogeneity on mortality prediction in a cohort of septic shock patients. NE doses were converted from the base molecule to equivalent salt doses, and their ability to predict 28-day mortality at common severity dose cut-offs was compared.

RESULTS

4086 eligible patients with septic shock were identified, with a median age of 68 [57-78] years, an admission SOFA score of 7 [6-10], and lactate at diagnosis of 3.2 [2.4-5.1] mmol/L. Median peak NE dose at day 1 was 0.24 [0.12-0.42] μg/kg/min, with a 28-day mortality of 39.3%. The NE dose showed significant heterogeneity in mortality prediction depending on which formulation was reported, with doses reported as bitartrate and tartrate presenting 65 (95% CI 79-43)% and 67 (95% CI 80-47)% lower ORs than base molecule, respectively. This divergence in prediction widened at increasing NE doses. When using a 1 μg/kg/min threshold, predicted mortality was 54 (95% CI 52-56)% and 83 (95% CI 80-87)% for tartrate formulation and base molecule, respectively.

CONCLUSIONS

Heterogeneous reporting of NE doses significantly affects mortality prediction in septic shock. Standardizing NE dose reporting as base molecule could enhance risk stratification and improve processes of care. These findings underscore the importance of consistent NE dose reporting practices in critical care settings.

Position Paper on the Reporting of Norepinephrine Formulations in Critical Care from the Society of Critical Care Medicine and European Society of Intensive Care Medicine Joint Task Force

OBJECTIVES

To provide guidance on the reporting of norepinephrine formulation labeling, reporting in publications, and use in clinical practice.

DESIGN

Review and task force position statements with necessary guidance.

SETTING

A series of group conference calls were conducted from August 2023 to October 2023, along with a review of the available evidence and scope of the problem.

SUBJECTS

A task force of multinational and multidisciplinary critical care experts assembled by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine.

INTERVENTIONS

The implications of a variation in norepinephrine labeled as conjugated salt (i.e., bitartrate or tartrate) or base drug in terms of effective concentration of norepinephrine were examined, and guidance was provided.

MEASUREMENTS AND MAIN RESULTS

There were significant implications for clinical care, dose calculations for enrollment in clinical trials, and results of datasets reporting maximal norepinephrine equivalents. These differences were especially important in the setting of collaborative efforts across countries with reported differences.

CONCLUSIONS

A joint task force position statement was created outlining the scope of norepinephrine-dose formulation variations, and implications for research, patient safety, and clinical care. The task force advocated for a uniform norepinephrine-base formulation for global use, and offered advice aimed at appropriate stakeholders.

Angiotensin ii therapy in refractory septic shock: which patient can benefit most? A narrative review

Patients with septic shock who experience refractory hypotension despite adequate fluid resuscitation and high-dose noradrenaline have high mortality rates. To improve outcomes, evidence-based guidelines recommend starting a second vasopressor, such as vasopressin, if noradrenaline doses exceed 0.5 µg/kg/min. Recently, promising results have been observed in treating refractory hypotension with angiotensin II, which has been shown to increase mean arterial pressure and has been associated with improved outcomes. This narrative review aims to provide an overview of the pathophysiology of the renin-angiotensin system and the role of endogenous angiotensin II in vasodilatory shock with a focus on how angiotensin II treatment impacts clinical outcomes and on identifying the population that may benefit most from its use.

Catastrophic Streptococcus pyogenes Disease: A Personalized Approach Based on Phenotypes and Treatable Traits

Streptococcal toxic shock syndrome (STTS) is a critical medical emergency marked by high morbidity and mortality, necessitating swift awareness, targeted treatment, and early source control due to its rapid symptom manifestation. This report focuses on a cohort of 13 patients admitted to Vall d'Hebron University Hospital Intensive Care Unit, Barcelona, from November 2022 to March 2023, exhibiting invasive Streptococcus pyogenes infections and meeting institutional sepsis code activation criteria. The primary infections were community-acquired pneumonia (61.5%) and skin/soft tissue infection (30.8%). All patients received prompt antibiotic treatment, with clinical source control through thoracic drainage (30.8%) or surgical means (23.1%). Organ support involved invasive mechanical ventilation, vasopressors, and continuous renal replacement therapy as per guidelines. Of note, 76.9% of patients experienced septic cardiomyopathy, and 53.8% required extracorporeal membrane oxygenation (ECMO). The study identified three distinct phenotypic profiles-hyperinflammatory, low perfusion, and hypogammaglobulinemic-which could guide personalized therapeutic approaches. STTS, with a mean SOFA score of 17 (5.7) and a 53.8% requiring ECMO, underscores the need for precision medicine-based rescue therapies and sepsis phenotype identification. Integrating these strategies with prompt antibiotics and efficient source control offers a potential avenue to mitigate organ failure, enhancing patient survival and recovery in the face of this severe clinical condition.

Heterogeneity in defining multiple trauma: a systematic review of randomized controlled trials

INTRODUCTION

While numerous randomized controlled trials (RCTs) have been conducted in the field of trauma, a substantial portion of them are yielding negative results. One potential contributing factor to this trend could be the lack of agreement regarding the chosen definitions across different trials. The primary objective was to identify the terminology and definitions utilized for the characterization of multiple trauma patients within randomized controlled trials (RCTs).

METHODS

A systematic review of the literature was performed in MEDLINE, EMBASE and clinicaltrials.gov between January 1, 2002, and July 31, 2022. RCTs or RTCs protocols were eligible if they included multiple trauma patients. The terms employed to characterize patient populations were identified, and the corresponding definitions for these terms were extracted. The subsequent impact on the population recruited was then documented to expose clinical heterogeneity.

RESULTS

Fifty RCTs were included, and 12 different terms identified. Among these terms, the most frequently used were "multiple trauma" (n = 21, 42%), "severe trauma" (n = 8, 16%), "major trauma" (n = 4, 8%), and trauma with hemorrhagic shock" (n = 4, 8%). Only 62% of RCTs (n = 31) provided a definition for the terms used, resulting a total of 21 different definitions. These definitions primarily relied on the injury severity score (ISS) (n = 15, 30%), displaying an important underlying heterogeneity. The choice of the terms had an impact on the study population, affecting both the ISS and in-hospital mortality. Eleven protocols were included, featuring five different terms, with "severe trauma" being the most frequent, occurring six times (55%).

CONCLUSION

This systematic review uncovers an important heterogeneity both in the terms and in the definitions employed to recruit trauma patients within RCTs. These findings underscore the imperative of promoting the use of a unique and consistent definition.