Refractory Septic Shock Vasopressors — FRCA Final MCQ

Instant feedback + full explanation. One question, done properly.

ModerateIntensive Care MedicineRefractory Septic Shock VasopressorsFRCA Final

A 60-year-old man in the ICU has septic shock despite adequate fluid resuscitation and source-control measures. There is no echocardiographic or haemodynamic evidence of myocardial dysfunction or a low-output state. He is receiving noradrenaline 0.8 micrograms/kg/min and vasopressin 0.03 units/min, but his mean arterial pressure remains 58 mmHg. According to the 2026 Surviving Sepsis Campaign guidelines, which vasoactive agent should be added next?

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

Reveal the answer and explanation

Correct answer: A — Adrenaline

Adrenaline is the appropriate additional vasopressor when adequately resuscitated septic shock remains hypotensive despite noradrenaline and vasopressin. Its alpha-1 activity increases systemic vascular resistance, while beta-1 activity may augment cardiac output, although tachyarrhythmias and increased lactate production can occur. Dobutamine is primarily an inotrope and is considered when septic myocardial dysfunction or persistent hypoperfusion from low cardiac output is present; these have been excluded in the stem. Dopamine carries a greater risk of tachyarrhythmia and is not preferred over noradrenaline. Phenylephrine provides pure alpha-adrenergic vasoconstriction but may reduce stroke volume and is not the recommended routine third agent. Terlipressin has a longer, less readily titratable action than vasopressin and is not recommended for this role.

Reference: Prescott HC et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026, haemodynamic management/vasoactive agents section. Critical Care Medicine. 2026;54:725–812. https://pubmed.ncbi.nlm.nih.gov/41869847/