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Challenges in the management of septic shock: a narrative review

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.

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Correspondence to Daniel De Backer.

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Conflicts of interest

Daniel De Backer: consultant to and material for studies by Edwards Lifesciences. Maurizio Cecconi: consultancy for Edwards Lifesciences, LiDCO, Cheetah, Masimo. Jeffrey Lipman: MSD (Australia)—Antibacterials Advisory Board; honoraria for lectures—Pfizer South Africa, MSD South Africa; committee—Pfizer International 2018 Anti-Infectives. Flavia Machado: member of steering committee for BASIC study, for which drug was supplied by Baxter. Sheila Nainan Myatra: no conflict of interest. Marlies Ostermann: research funding from Ja Jolla Pharma. Anders Perner: Dept. of Intensive Care at Rigshospitalet has received support for research from CSL Behring, Fresenius Kabi, and Ferring Pharmaceutical. Jean-Louis Teboul: member of the medical advisory board of Pulsion/Getinge (Germany). Jean Louis Vincent: no conflict of interest. Keith Walley: no conflict of interest.

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De Backer, D., Cecconi, M., Lipman, J. et al. Challenges in the management of septic shock: a narrative review. Intensive Care Med 45, 420–433 (2019). https://doi.org/10.1007/s00134-019-05544-x

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Keywords

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