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Refractory Septic Shock — FRCA Final MCQ

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ModerateIntensive Care MedicineRefractory Septic ShockFRCA Final

A 70-year-old man is in ICU following laparotomy and Hartmann's procedure for perforated sigmoid diverticulitis. Source control is complete, culture-directed antimicrobials are running and he has been adequately fluid resuscitated; echocardiography shows adequate cardiac output with no myocardial dysfunction. For the past 6 hours he has required noradrenaline 0.3 micrograms/kg/min and vasopressin 0.03 units/min, and his mean arterial pressure is 62 mmHg. A random serum cortisol concentration is 350 nmol/L. Which additional treatment should now be started to facilitate shock reversal?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Start intravenous hydrocortisone 50 mg every 6 hours

Explanation lettering: C = shown as A · E = shown as B · A = shown as C · B = shown as E

This is persistent vasopressor-dependent septic shock despite source control, antimicrobials and adequate fluid resuscitation. Intravenous hydrocortisone 200 mg/day (50 mg six-hourly, or by infusion) is the recommended adjunct once noradrenaline requirement is at least 0.25 micrograms/kg/min for four hours or more; its main effect is faster shock reversal and vasopressor weaning, with less certain mortality benefit. Selection is by clinical vasopressor dependence, not biochemistry: critical illness alters cortisol secretion, protein binding and metabolism, so a random cortisol (E) or a short Synacthen test (B) should not gate treatment. Noradrenaline is still titrated to target, but escalation alone (C) omits the indicated adjunct. Adrenaline (D) is a later rescue option in low-output states, not required before hydrocortisone here.

Reference: Evans L et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021 — corticosteroids in vasopressor-dependent septic shock (Intensive Care Med, 2021). https://pubmed.ncbi.nlm.nih.gov/34599691/