Refractory septic shock to norepinephrine

A refractory shock to norepinephrine, in the absence of consensual definition, is suggested by a vasoplegic shock that does not respond to a dosage of norepinephrine above 0.5 mu g/kg/min. Vasopressin has a synergic effect when administered at low dose with norepinephrine. Its use as last step therapy did not result in improved survival. However, its effect in combination with norepinephrinemayresult in improved organ failure resolution. Its usewas associated with less atrial fibrillation, and improved renal function. Interesting findingswere reportedwith the use ofangiotensin II, but those results are too preliminary. The NO inhibitors should not be used before new randomised clinical trials are conducted. Extracorporeal membrane oxygenation systems are a salvage procedure, which are supported byonly fewobservational data. An earlyandmultimodal strategy seems themost promising way to progress for the management of patients with septic shock.