Evidence map›Paper›PMID 41874620›Full record

ArticleIntensive care medicine2026

Clinical criteria for the definition of refractory septic shock: a joint Delphi consensus from the Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM).

Marc Leone, Sheila N Myatra, Siddharth Dugar, Patrick M Wieruszewski, Lene Russell, Laura Evans, Louis Delamarre, Sameer Sharif, Michelle S Chew, Michelle Ng Gong and 55 more

Registry-linked trialAbstract readConsensus Statement
PubMed Publisher
In one paragraph

Article in Intensive care medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to trial NCT07715110 (Biological and Immunomodulatory Effect of Hemoadsorption With Macroporous Resin Cartridges in Septic Shock and Refractory Septic Shock Two Parallel Open-label Randomized Pilot Trials.), which is not on this map. Cited by 5 papers.

0numbers the graph read from it
0cells of the map it votes in
5citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

NCT07715110 nanot yet recruitingnot on this mapstarted 2027, after this paper: background citation

Biological and Immunomodulatory Effect of Hemoadsorption With Macroporous Resin Cartridges in Septic Shock and Refractory Septic Shock Two Parallel Open-label Randomized Pilot Trials.

TypeinterventionalSponsorMiguel Sanchez GarciaRan2027 to 2029Enrolled16ConditionsSeptic Shock, Vasopressor Resistance, Multiple Organ Dysfunction, Sepsis, HemoperfusionArmsHemoadsorption cartridge
3 · Its place in the literature

Who cites it

5 citing papers in PubMed.

  1. Article
  2. Article
  3. Article
  4. Review
  5. Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

65 authors.

Marc LeoneDepartment of Anesthesiology and Intensive Care Medicine, Nord Hospital, Assistance Publique Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France. marc.leone@ap-hm.fr.ORCID http://orcid.org/0000-0002-3097-758X
Sheila N MyatraDepartment of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.ORCID http://orcid.org/0000-0001-6761-163X
Siddharth DugarDepartment of Critical Care Medicine, Integrated Hospital-Care Institute (IHI), Cleveland Clinic, Cleveland, OH, USA.ORCID http://orcid.org/0000-0002-3243-1417
Patrick M WieruszewskiDepartment of Anesthesiology, Mayo Clinic, and Department of Pharmacy, Mayo Clinic, Rochester, MN, USA.ORCID http://orcid.org/0000-0002-5871-5186
Lene RussellDepartment of Intensive Care, Copenhagen University Hospital Gentofte, Hellerup, Denmark.ORCID http://orcid.org/0000-0001-7352-8728
Laura EvansDivision of Pulmonary, Critical Care and Sleep Medicine, University of Washington Medical Center, Seattle, WA, USA.ORCID http://orcid.org/0000-0002-0292-0172
Louis DelamarreDepartment of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, Gui De Chauliac, Montpellier, France.ORCID http://orcid.org/0000-0002-4051-3834
Sameer SharifDivisions of Emergency Medicine and Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.ORCID http://orcid.org/0000-0002-3346-0308
Michelle S ChewPerioperative Medicine and Intensive Care, Karolinska University Hospital Huddinge and Division of Anesthesiology and Intensive Care CLINTEC, Karolinska Institute, Stockholm, Sweden.ORCID http://orcid.org/0000-0003-2888-4111
Michelle Ng GongDivision of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.ORCID http://orcid.org/0000-0001-7952-5384
Glenn HernándezDepartamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile.ORCID http://orcid.org/0000-0002-3032-4087
Christa SchorrCooper University Hospital, Cooper Research Institute, Critical Care, Camden, NJ, USA.ORCID http://orcid.org/0000-0001-7777-4280
Ines LakbarAnesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, INSERM U1046, 1, University of Montpellier, Montpellier, France.ORCID http://orcid.org/0000-0003-0049-6248
Susan E SmithDepartment of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA.ORCID http://orcid.org/0000-0002-5171-8405
Ignacio Martin-LoechesDepartment of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organisation (MICRO), Trinity College Dublin, St James's Hospital, Dublin, Ireland.ORCID http://orcid.org/0000-0002-5834-4063
Djillali AnnaneService de Réanimation, Comprehensive Sepsis Centre PROMETHEUS, Hôpital Raymond Poincaré, Assistance Publique-Hôpitaux de Paris, Université Versailles Saint-Quentin, Garches, Versailles, France.ORCID http://orcid.org/0000-0001-6805-8944
Martin BalikDepartment of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.ORCID http://orcid.org/0000-0003-1864-2143
Maurizio CecconiBiomedical Sciences Department, Humanitas University, Pieve Emanuele, Milan, Italy.ORCID http://orcid.org/0000-0002-4376-6538
Daniel De BackerDepartment of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium.ORCID http://orcid.org/0000-0001-9841-5762
Katia DonadelloDepartment of Surgery, Anaesthesia and Intensive Care Unit B, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy.ORCID http://orcid.org/0000-0002-7053-8434
Martin W DünserDepartment of Anesthesiology and Intensive Care Medicine, Kepler University Hospital, Johannes Kepler University, Linz, Austria.
Sharon EinavFaculty of Medicine, Maccabi Healthcare System and Hebrew University, Jerusalem, Israel.ORCID http://orcid.org/0000-0001-8963-9633
Ricard FerrerIntensive Care Department, Hospital Universitari Vall d'Hebron, Barcelona Autonomous University, Barcelona, Spain.ORCID http://orcid.org/0000-0002-4859-4747
Nicole JuffermansIntensive Care Unit, Erasmus Medical Center, Rotterdam, the Netherlands.ORCID http://orcid.org/0000-0002-3039-6574
Olfa HamzaouiUnité de Médecine Intensive et Réanimation Polyvalente, Unité PPF "Pharmacologie et Pathologies Fragilisantes"-UR 3801, CHU Reims, Université de Reims Champagne-Ardenne, Reims, France.ORCID http://orcid.org/0000-0002-8885-2114
Giovanni LandoniDepartment of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.ORCID http://orcid.org/0000-0002-8594-5980
Bruno LevyMédecine Intensive et Réanimation, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-Les-Nancy, France.ORCID http://orcid.org/0000-0002-7007-3219
Cathrine McKenzieBiomedical Research Centre, Perioperative and Critical Care Theme, National Institute of Health and Social Care Research, University of Southampton, Southampton, UK.ORCID http://orcid.org/0000-0002-5190-9711
Xavier MonnetService de Médecine Intensive-Réanimation, Groupe de Recherche Clinique CARMAS, AP-HP, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, Comprehensive Sepsis Centre, Université Paris-Saclay, Le Kremlin-Bicêtre, France.ORCID http://orcid.org/0000-0001-6820-2678
Marlies OstermannDepartment of Intensive Care, King's College London, Guy's & St Thomas' Hospital, London, UK.ORCID http://orcid.org/0000-0001-9500-9080
Claudia SpiesDepartment of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany.ORCID http://orcid.org/0000-0002-1062-0495
Mervyn SingerBloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK.ORCID http://orcid.org/0000-0002-1042-6350
Maria TheodorakopulouIntensive Care Unit, General Hospital of Athens "KAT", Athens, Greece.ORCID http://orcid.org/0000-0001-6216-9635
Arzu TopeliDepartment of Internal Medicine, Division of Intensive Care, Sepsis Research, Education and Practice Center, Hacettepe University Faculty of Medicine, Ankara, Turkey.ORCID http://orcid.org/0000-0002-5874-9087
Erin BarretoDepartment of Pharmacy, Mayo Clinic, Rochester, MN, USA.ORCID http://orcid.org/0000-0002-0996-1487
Seth R BauerDepartment of Pharmacy, Cleveland Clinic, Cleveland, OH, USA.ORCID http://orcid.org/0000-0002-0420-0320
Laurence W BusseDepartment of Medicine, Emory Critical Care Center, Emory Healthcare, Emory University School of Medicine, Atlanta, GA, USA.ORCID http://orcid.org/0000-0002-6564-5200
Craig M CoopersmithDepartment of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA, USA.ORCID http://orcid.org/0000-0003-2400-3217
Clifford DeutschmanCohen Children's Medical Center, The Zucker School of Medicine at Northwell/Hofstra, The Feinstein Institute for Medical Research, Manhasset, NY, USA.ORCID http://orcid.org/0000-0001-9490-4024
Andre L HolderDivision of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA.ORCID http://orcid.org/0000-0003-2635-3923
Rishikesan KamaleswaranDepartment of Biomedical Engineering and Electrical and Computer Engineering, Duke University, Durham, NC, USA.ORCID http://orcid.org/0000-0001-8366-4811
Matthieu LegrandDepartment of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA.ORCID http://orcid.org/0000-0001-9788-5316
Greg S MartinDivision of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA.ORCID http://orcid.org/0000-0002-9684-7593
Ryan C MavesDivision of Critical Care Medicine, Department of Anesthesiology, Division of Infectious Diseases, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.ORCID http://orcid.org/0000-0001-6234-6160
Lama NazerKing Hussein Cancer Center, Amman, Jordan.ORCID http://orcid.org/0000-0002-7550-4751
Mark E NunnallyDepartment of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, New York, NY, USA.ORCID http://orcid.org/0000-0003-2129-4733
Hallie C PrescottDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ann Arbor, MI, USA.ORCID http://orcid.org/0000-0002-8442-6724
Teresa RinconTan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, MA, USA.ORCID http://orcid.org/0000-0003-2655-2543
Gretchen L SachaDepartment of Pharmacy, Cleveland Clinic, Cleveland, OH, USA.ORCID http://orcid.org/0000-0002-0070-8100
Chris W SeymourDepartment of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA.ORCID http://orcid.org/0000-0002-6257-6764
Yaseen M ArabiIntensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.ORCID http://orcid.org/0000-0001-5735-6241
Bruno A M P BesenIntensive Care Department, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.ORCID http://orcid.org/0000-0002-3516-9696
Alexandre Biasi CavalcantiDivision of Anesthesiology. Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil.ORCID http://orcid.org/0000-0003-2798-6263
Adam M DeaneDepartment of Critical Care, Melbourne Medical School, & Intensive Care Unit, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia.ORCID http://orcid.org/0000-0002-7620-5577
Simon FinferThe George Institute for Global Health, University of New South Wales, Sydney, Australia.ORCID http://orcid.org/0000-0002-2785-5864
Naomi HammondThe George Institute for Global Health, University of New South Wales, Sydney, Australia.ORCID http://orcid.org/0000-0002-6559-7747
Miguel Ibarra-EstradaDepartment of Intensive Care Unit, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, México.ORCID http://orcid.org/0000-0001-8914-4171
Eduardo KattanDepartamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.ORCID http://orcid.org/0000-0002-1997-6893
Yuki KotaniDepartment of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan.ORCID http://orcid.org/0000-0002-9532-2859
Flavia R MachadoIntensive Care Department, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.ORCID http://orcid.org/0000-0002-2356-4867
Gustavo A Ospina-TascónDepartment of Intensive Care, Fundación Valle del Lili, Cali, Colombia.ORCID http://orcid.org/0000-0001-9370-3298
Mervyn MerDepartment of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.ORCID http://orcid.org/0000-0003-3338-8251
Paul J YoungIntensive Care Unit, Wellington Hospital, Wellington, New Zealand.ORCID http://orcid.org/0000-0002-3428-3083
Bram RochwergDivision of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.ORCID http://orcid.org/0000-0002-8293-7061
Ashish K KhannaDepartment of Anesthesiology, Division of Critical Care Medicine, Atrium Health Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, NC, USA.ORCID http://orcid.org/0000-0002-9114-6739

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

objectiveA definition of refractory septic shock is necessary to guide diagnosis, management, prognostication, research, and future guidelines for this most severe form of the disease. We sought to achieve consensus on clinical criteria that would be used to define refractory septic shock.

designReview of literature, expert panel position statements, and Delphi rounds with an international expert group.

settingConsensus was defined as having at least 75% of panellists in agreement or disagreement on the three highest or lowest levels of a 7-point Likert scale or based on responses to single- or multiple-choice questions, respectively. SUBJECTS: A panel of multinational, multiprofessional, and multidisciplinary critical care experts assembled by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine (57 invitations and 56 participants). MEASUREMENTS AND MAIN

resultsA five-round Delphi process was conducted for consensus and stability. The steering committee proposed 34 statements, and five of them were rejected by panel experts after round 2. Among 29 statements selected from eight domains, consensus was reached for 13. The panel agreed on the need for a comprehensive consensus set of clinical criteria for refractory septic shock. Markers of organ dysfunction (75%, 2 rounds), tissue perfusion (91.1%, 2 rounds) including lactate (94.6%, 2 rounds) and capillary refill time (76.8%, 2 rounds), assessment of fluid responsiveness after initial resuscitation (92.9%, 5 rounds), and use of vasoactive drugs at norepinephrine equivalents greater than 0.5 µg/kg/min (75.0%, 3 rounds) were selected as clinical criteria of refractory septic shock. The use of critical care ultrasound (CCUS) (92.9%, 3 rounds) was the single diagnostic modality that reached a consensus-based agreement.

conclusionsA consensus for 13 criteria to frame the definition of refractory septic shock was reached. Refractory septic shock is characterised by persistently elevated lactate concentrations and or prolonged capillary refill time in patients with septic shock who are fluid unresponsive, require a norepinephrine base equivalent dose greater than 0.5 µg per kilogram per minute, and undergo CCUS assessment when mixed shock is suspected.

Indexed as

Critical CareShock, SepticBiomarkersDelphi TechniqueEuropeHumansSocieties, MedicalBiomarkersConceptCriteriaDefinitionRefractorySepsisSeptic shock

Identifiers

PMID41874620

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Registered trials

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