The Role of Adjunctive Therapies and Supportive Care in Septic Shock

There are many challenges related to strategies for mechanical ventilation adjustment, the use of corticosteroids, plasma exchange, continuous kidney replacement therapy (CKRT), ECMO, IVIG administration, and nutritional support in the management of patients with septic shock. Respiratory Support: recent recommendations suggest early intubation in patients who remain fluid-refractory, even before respiratory failure develops. Etomidate should not be used for intubation. In patients with acute respiratory failure who do not meet indications for intubation, non-invasive ventilation (NIV) may be considered. Mechanical ventilation settings should follow the criteria for pediatric acute respiratory failure (if it occurs). Endocrine Issues: if the patient's hemodynamics remain unstable despite fluids and vasopressors, or if adrenal insufficiency is diagnosed, intravenous hydrocortisone is recommended. Blood glucose should preferably be maintained below ۱۸۰ mg/dl. Nutritional Care: nutritional support is of particular importance in septic shock. Enteral feeding should not be discontinued solely due to the use of vasoactive-inotropic agents, and early enteral feeding within the first ۴۸ hours (in the absence of abdominal contraindications) is advised. There is insufficient evidence to support or oppose the use of intralipids, vitamin C, or zinc supplementation. Transfusion it is recommended to maintain hemoglobin levels preferably above ۷ g/dl in septic shock. Prophylactic use of other blood products is not advised. Adjunctive Therapies no specific recommendations are made for plasma exchange. However, early initiation of CKRT is emphasized for the prevention or treatment of fluid overload in septic shock that leads to organ dysfunction and does not respond to fluid restriction or diuretics. Indications for venovenous ECMO include septic shock-associated acute respiratory failure with refractory hypoxemia, while venoarterial ECMO is reserved for shock resistant to other therapies. Other Therapies: additional interventions discussed include IVIG, pantoprazole (for stress ulcer prophylaxis), and pharmacological or mechanical prophylaxis for deep vein thrombosis. However, their routine use is not recommended.