Vasodilatory Shock—From Initial Resuscitation to Rescue Therapies: Narrative Review and Considerations for Critical Care Transport

Vasodilatory shock is a critical condition marked by maldistribution of blood flow leading to decreased oxygen delivery and organ dysfunction. Although sepsis is the most well-studied cause, other causes include anaphylaxis, endocrine or neurologic dysfunction, toxidromes, and the post-cardiac arrest or post-cardiopulmonary bypass state. After appropriate volume resuscitation, vasopressors may be added in a stepwise manner targeting a mean arterial pressure of >65 mm Hg to ensure organ perfusion. If a patient does not respond adequately to these initial measures, a “resuscitation checkpoint” can be used as a debiasing strategy to consider other contributing factors to shock. If cardiac dysfunction is present, consider addition of inotropes. Metabolic resuscitation may be accomplished in appropriate patients with corticosteroids, calcium, or sodium bicarbonate. Finally, emerging treatments may be considered for refractory vasodilatory shock, including angiotensin II, methylene blue, and hydroxocobalamin. Overall, this review presents an evidence-based tiered approach to management of refractory vasodilatory shock in critical care transport.