Shock is a condition when there is a discrepancy between the needs of the tissues and their supply of oxygen and nutrients. It is due to the dysfunction of the circulatory system in providing blood to the tissues to adequately meet the metabolic requirements and the insufficient removal of waste products of metabolism. The most common cause of shock in the pediatric population is hypovolemic shock, whereas, in adults, it is septic shock. Refractory shock is variably defined as persistent hypotension with end-organ dysfunction despite fluid resuscitation, high-dose vasopressors, oxygenation, and ventilation. Fluid resuscitation and vasopressors are the initial approaches to the management of shock. Overuse of fluids in critically ill patients can lead to pulmonary edema, hypoxemic respiratory failure, and organ edema.
High doses of catecholamines can induce arrhythmias and ischemia. The strongest predictor of mortality in critically ill patients is the vasopressor dose that is required to maintain the mean arterial pressure (MAP) goal. High dose vasopressor doses can be defined by converting other vasopressors to norepinephrine equivalents of > 0.2 micrograms/kg/min. There are no standard guidelines for the management of refractory shock, but a few randomized studies guide clinical management.
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