Despite timely intervention, there exists a small subgroup of patients with septic shock who develop progressive multi-organ failure. Seemingly refractory to conventional therapy, they exhibit a very high mortality. Such patients are often poorly represented in large clinical trials.

The management of refractory septic shock remains extremely challenging. We believe that where established conventional interventions fail to deliver improvements, a different approach using pragmatic strategies is necessary.

Many of the interventions described here have proven biological plausibility but lack conclusive evidence. However, many remain unstudied in the context of refractory septic shock.

Most of these strategies are relatively inexpensive, widely accessible, and are likely to be available in the majority of institutions. Our collective belief is that a bespoke approach can help to achieve hemodynamic stability and reverse progressive deterioration in this small subgroup of critically ill patients with a very high mortality.

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