Sepsis — Fluid Refractory Shock and Catecholamine Resistant Shock — Clinical Pathway: Emergency Department, Inpatient and PICU

Sepsis Clinical Pathway — Emergency Department, Inpatient and PICU

Fluid Refractory Shock and Catecholamine Resistant Shock

Fluid Refractory Shock

Shock persists despite 40-60 mL/kg fluid resuscitation

  • Assess Cardiac Function
    • Obtain bedside cardiac ultrasound or echocardiogram to assess cardiac function
    • If ultrasound unable to be completed, do NOT delay vasoactive medication
    • Consider serial assessments of cardiac function if increasing SVR with vasoactive medications
    • Cardiology consult if question of systolic dysfunction on bedside echocardiogram

Initiate Vasoactive Therapy

Vasoactive therapies can be initiated peripherally.
Consider arterial line, CVL, Foley for patients on vasoactive infusion for > 1 hour

DO NOT DELAY initiation of vasoactive therapy to obtain cardiac function assessment.

  • If imaging not available, assume decreased function in the setting of fluid refractive shock.
  • Initiate direct acting catecholamine (epinephrine or norepinephrine) per provider discretion.

First Line Recommendations

Vasoactive Dose Considerations Cautions
Epinephrine Starting dose:
0.05 mcg/kg/min
  • Recommended First Line Agent
    • Preferred inotropic agent if known/suspected myocardial dysfunction
 Consider patient physiology, clinical preference and local systems factors when selecting first line catecholamine.
Norepinephrine Starting dose:
0.05 mcg/kg/min
  • Alternative First Line Agent
    • Will increase SVR more than starting doses of epinephrine, so consider instead of epinephrine for vasodilated (“warm”) shock ( more common sepsis presentation for adolescents/adults)
Dopamine 5 mcg/kg/min May substitute as the first line vasoactive if epinephrine/norepinephrine not readily available

Catecholamine Resistant Shock

Vasoactive Dose Considerations Cautions
Milrinone 0.3 mcg/kg/min Consider if persistent hypoperfusion and cardiac dysfunction despite other agents May cause hypotension
Dobutamine 5 mcg/kg/min Consider if persistent hypoperfusion and cardiac dysfunction despite other agents
Vasopressin 12 milli-units/kg/hr Consider if requiring high-dose catecholamines