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Intensive Care Med. 2019 Apr;45(4):420-433. doi: 10.1007/s00134-019-05544-x. Epub 2019 Feb 11.

Challenges in the management of septic shock: a narrative review.

Author information

1
Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium. ddebacke@ulb.ac.be.
2
Department Anaesthesia and Intensive Care Units, IRCCS Istituto Clinico Humanitas, Humanitas University, Milan, Italy.
3
Intensive Care Services, Royal Brisbane and Women's Hospital and The University of Queensland Centre for Clinical Research, Brisbane, Australia.
4
Anesthesiology, Pain and Intensive Care Department, Federal University of Sao Paulo, São Paulo, Brazil.
5
Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India.
6
Department of Intensive Care, King's College London, Guy's & St Thomas' Hospital, London, UK.
7
Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
8
Medical Intensive Care Unit, Bicetre Hospital, Paris-South University Hospitals, Inserm UMR_S999, Paris-South University, Le Kremlin-Bicêtre, France.
9
Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
10
Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada.

Abstract

While guidelines provide important information on how to approach a patient in septic shock, "many challenges remain" for the management of these patients. In this narrative review, the panel discusses the challenges in identifying the right hemodynamic target, optimization of fluid therapy, selection of vasopressor agents, identification of patients who may benefit from inotropic agents or on the contrary beta-blockade, and use of steroids. The place for microcirculation-targeted therapy is debated as well as the use of alternative techniques (blood purification) and therapies (vitamin C). The implications of hemodynamic alterations on antibiotic doses is discussed. Finally, the specific challenges in low- and middle-income countries are addressed. Ongoing trials address some of these challenges, but many uncertainties will remain, and individualized therapies based on careful clinical assessment will continue to be essential to optimizing the care of patients with septic shock.

KEYWORDS:

Cardiac output; Fluids; Hemodynamic monitoring; Steroids; Tissue perfusion; Vasopressors

PMID:
30741328
DOI:
10.1007/s00134-019-05544-x

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