Intensive Care Medicine

, Volume 45, Issue 4, pp 420–433 | Cite as

Challenges in the management of septic shock: a narrative review

  • Daniel De BackerEmail author
  • Maurizio Cecconi
  • Jeffrey Lipman
  • Flavia Machado
  • Sheila Nainan Myatra
  • Marlies Ostermann
  • Anders Perner
  • Jean-Louis Teboul
  • Jean-Louis Vincent
  • Keith R. Walley


While guidelines provide important information on how to approach a patient in septic shock, “many challenges remain” for the management of these patients. In this narrative review, the panel discusses the challenges in identifying the right hemodynamic target, optimization of fluid therapy, selection of vasopressor agents, identification of patients who may benefit from inotropic agents or on the contrary beta-blockade, and use of steroids. The place for microcirculation-targeted therapy is debated as well as the use of alternative techniques (blood purification) and therapies (vitamin C). The implications of hemodynamic alterations on antibiotic doses is discussed. Finally, the specific challenges in low- and middle-income countries are addressed. Ongoing trials address some of these challenges, but many uncertainties will remain, and individualized therapies based on careful clinical assessment will continue to be essential to optimizing the care of patients with septic shock.


Hemodynamic monitoring Cardiac output Tissue perfusion Vasopressors Fluids Steroids 


Compliance with ethical standards

Conflicts of interest

Daniel De Backer: consultant to and material for studies by Edwards Lifesciences. Maurizio Cecconi: consultancy for Edwards Lifesciences, LiDCO, Cheetah, Masimo. Jeffrey Lipman: MSD (Australia)—Antibacterials Advisory Board; honoraria for lectures—Pfizer South Africa, MSD South Africa; committee—Pfizer International 2018 Anti-Infectives. Flavia Machado: member of steering committee for BASIC study, for which drug was supplied by Baxter. Sheila Nainan Myatra: no conflict of interest. Marlies Ostermann: research funding from Ja Jolla Pharma. Anders Perner: Dept. of Intensive Care at Rigshospitalet has received support for research from CSL Behring, Fresenius Kabi, and Ferring Pharmaceutical. Jean-Louis Teboul: member of the medical advisory board of Pulsion/Getinge (Germany). Jean Louis Vincent: no conflict of interest. Keith Walley: no conflict of interest.

Ethics approval

An approval by an ethics committee was not applicable.

Supplementary material

134_2019_5544_MOESM1_ESM.docx (107 kb)
Supplementary material 1 (DOCX 107 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Daniel De Backer
    • 1
    Email author
  • Maurizio Cecconi
    • 2
  • Jeffrey Lipman
    • 3
  • Flavia Machado
    • 4
  • Sheila Nainan Myatra
    • 5
  • Marlies Ostermann
    • 6
  • Anders Perner
    • 7
  • Jean-Louis Teboul
    • 8
  • Jean-Louis Vincent
    • 9
  • Keith R. Walley
    • 10
  1. 1.Department of Intensive Care, CHIREC HospitalsUniversité Libre de BruxellesBrusselsBelgium
  2. 2.Department Anaesthesia and Intensive Care Units, IRCCS Istituto Clinico HumanitasHumanitas UniversityMilanItaly
  3. 3.Intensive Care ServicesRoyal Brisbane and Women’s Hospital and The University of Queensland Centre for Clinical ResearchBrisbaneAustralia
  4. 4.Anesthesiology, Pain and Intensive Care DepartmentFederal University of Sao PauloSão PauloBrazil
  5. 5.Department of Anaesthesiology, Critical Care and PainTata Memorial HospitalMumbaiIndia
  6. 6.Department of Intensive Care, King’s College LondonGuy’s & St Thomas’ HospitalLondonUK
  7. 7.Department of Intensive Care, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
  8. 8.Medical Intensive Care Unit, Bicetre Hospital, Paris-South University HospitalsInserm UMR_S999, Paris-South UniversityLe Kremlin-BicêtreFrance
  9. 9.Department of Intensive Care, Erasme University HospitalUniversité Libre de BruxellesBrusselsBelgium
  10. 10.Centre for Heart Lung InnovationUniversity of British ColumbiaVancouverCanada

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