{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,9]],"date-time":"2026-11-09T16:27:56Z","timestamp":1794241676285,"version":"4.9.0"},"reference-count":80,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"5","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,5]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVE:<\/jats:title>\n                    <jats:p>A 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>DESIGN:<\/jats:title>\n                    <jats:p>Review of literature, expert panel position statements, and Delphi rounds with an international expert group.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>SETTING:<\/jats:title>\n                    <jats:p>Consensus 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>SUBJECTS:<\/jats:title>\n                    <jats:p>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).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>MEASUREMENTS AND MAIN RESULTS:<\/jats:title>\n                    <jats:p>A 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 \u00b5g\/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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS:<\/jats:title>\n                    <jats:p>A 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 micrograms per kilogram per minute, and undergo CCUS assessment when mixed shock is suspected.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1097\/ccm.0000000000007124","type":"journal-article","created":{"date-parts":[[2026,3,24]],"date-time":"2026-03-24T12:00:45Z","timestamp":1774353645000},"page":"1073-1091","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":17,"title":["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)"],"prefix":"10.1097","volume":"54","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3097-758X","authenticated-orcid":false,"given":"Marc","family":"Leone","sequence":"first","affiliation":[{"name":"Department of Anesthesiology and Intensive Care Medicine, Nord Hospital, Assistance Publique H\u00f4pitaux Universitaires de Marseille, Aix Marseille University, Marseille, France."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6761-163X","authenticated-orcid":false,"given":"Sheila N.","family":"Myatra","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3243-1417","authenticated-orcid":false,"given":"Siddharth","family":"Dugar","sequence":"additional","affiliation":[{"name":"Department of Critical Care Medicine, Integrated Hospital-Care Institute (IHI), Cleveland Clinic, Cleveland, OH, USA."},{"name":"Department of Medicine, Case Western Reserve University, Cleveland, OH, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5871-5186","authenticated-orcid":false,"given":"Patrick M.","family":"Wieruszewski","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Mayo Clinic, and Department of Pharmacy, Mayo Clinic, Rochester, MN, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7352-8728","authenticated-orcid":false,"given":"Lene","family":"Russell","sequence":"additional","affiliation":[{"name":"Department of Intensive Care, Copenhagen, University Hospital Gentofte, Hellerup, Denmark."},{"name":"Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0292-0172","authenticated-orcid":false,"given":"Laura","family":"Evans","sequence":"additional","affiliation":[{"name":"Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington Medical Center, Seattle, WA, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4051-3834","authenticated-orcid":false,"given":"Louis","family":"Delamarre","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, Gui De Chauliac, Montpellier, France."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3346-0308","authenticated-orcid":false,"given":"Sameer","family":"Sharif","sequence":"additional","affiliation":[{"name":"Divisions of Emergency Medicine and Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada."},{"name":"Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2888-4111","authenticated-orcid":false,"given":"Michelle S.","family":"Chew","sequence":"additional","affiliation":[{"name":"Perioperative Medicine and Intensive Care, Karolinska University Hospital Huddinge and Division of Anesthesiology and Intensive Care CLINTEC, Karolinska Institute, Stockholm, Sweden."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7952-5384","authenticated-orcid":false,"given":"Michelle Ng","family":"Gong","sequence":"additional","affiliation":[{"name":"Division 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."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3032-4087","authenticated-orcid":false,"given":"Glenn","family":"Hern\u00e1ndez","sequence":"additional","affiliation":[{"name":"Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Cat\u00f3lica de Chile, Avenida Diagonal Paraguay, Santiago, Chile."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7777-4280","authenticated-orcid":false,"given":"Christa","family":"Schorr","sequence":"additional","affiliation":[{"name":"Cooper University Hospital, Cooper Research Institute, Critical Care, Camden, NJ, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0049-6248","authenticated-orcid":false,"given":"Ines","family":"Lakbar","sequence":"additional","affiliation":[{"name":"Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, Montpellier, France."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5171-8405","authenticated-orcid":false,"given":"Susan E.","family":"Smith","sequence":"additional","affiliation":[{"name":"Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5834-4063","authenticated-orcid":false,"given":"Ignacio","family":"Martin-Loeches","sequence":"additional","affiliation":[{"name":"Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organisation (MICRO), St James\u2019s Hospital, Trinity College Dublin, Dublin, Ireland."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6805-8944","authenticated-orcid":false,"given":"Djillali","family":"Annane","sequence":"additional","affiliation":[{"name":"Service de R\u00e9animation, Comprehensive Sepsis Centre PROMETHEUS, H\u00f4pital Raymond Poincar\u00e9, Assistance Publique-H\u00f4pitaux de Paris, Universit\u00e9 Versailles Saint-Quentin, Garches, Versailles, France."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1864-2143","authenticated-orcid":false,"given":"Martin","family":"Balik","sequence":"additional","affiliation":[{"name":"Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech 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and Intensive Care Unit B, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy."},{"name":"Anaesthesia and Intensive Care Unit B, University Hospital Integrated Trust of Verona, Verona, Italy."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin W.","family":"D\u00fcnser","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital, Johannes Kepler University, Linz, Austria."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8963-9633","authenticated-orcid":false,"given":"Sharon","family":"Einav","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Maccabi Healthcare System and Hebrew University, Jerusalem, Israel."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4859-4747","authenticated-orcid":false,"given":"Ricard","family":"Ferrer","sequence":"additional","affiliation":[{"name":"Intensive Care Department, Hospital Universitari Vall d\u2019Hebron, Barcelona Autonomous University, Barcelona, Spain."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3039-6574","authenticated-orcid":false,"given":"Nicole","family":"Juffermans","sequence":"additional","affiliation":[{"name":"Intensive Care Unit, Erasmus Medical Center, Rotterdam, the Netherlands."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8885-2114","authenticated-orcid":false,"given":"Olfa","family":"Hamzaoui","sequence":"additional","affiliation":[{"name":"Unit\u00e9 de M\u00e9decine Intensive et R\u00e9animation Polyvalente, Unit\u00e9 PPF \u201cPharmacologie et Pathologies Fragilisantes\u201d, Universit\u00e9 de Reims Champagne-Ardenne, Reims, France."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8594-5980","authenticated-orcid":false,"given":"Giovanni","family":"Landoni","sequence":"additional","affiliation":[{"name":"Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7007-3219","authenticated-orcid":false,"given":"Bruno","family":"Levy","sequence":"additional","affiliation":[{"name":"M\u00e9decine Intensive et R\u00e9animation, CHRU Nancy, P\u00f4le Cardio-M\u00e9dico-Chirurgical, Vandoeuvre\u2010Les\u2010Nancy, France."},{"name":"Facult\u00e9 de M\u00e9decine, INSERM U1116, Vandoeuvre\u2010Les\u2010Nancy, France."},{"name":"Universit\u00e9 de Lorraine, Nancy, France."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5190-9711","authenticated-orcid":false,"given":"Cathrine","family":"McKenzie","sequence":"additional","affiliation":[{"name":"Biomedical Research Centre, Perioperative and Critical Care Theme, National Institute of Health and Social Care Research, University of Southampton, Southampton, UK."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6820-2678","authenticated-orcid":false,"given":"Xavier","family":"Monnet","sequence":"additional","affiliation":[{"name":"Service de M\u00e9decine Intensive\u2010R\u00e9animation, Groupe de Recherche Clinique CARMAS, AP\u2010HP, H\u00f4pital de Bic\u00eatre, DMU CORREVE, Comprehensive Sepsis Centre, Universit\u00e9 Paris-Saclay, Le Kremlin\u2010Bic\u00eatre, France."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9500-9080","authenticated-orcid":false,"given":"Marlies","family":"Ostermann","sequence":"additional","affiliation":[{"name":"Department of Intensive Care, King\u2019s College London, Guy\u2019s & St Thomas\u2019 Hospital, London, UK."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1062-0495","authenticated-orcid":false,"given":"Claudia","family":"Spies","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Operative Intensive Care Medicine (CCM\/CVK), Charit\u00e9 \u2013 Universit\u00e4tsmedizin Berlin, Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin, Berlin, Germany."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1042-6350","authenticated-orcid":false,"given":"Mervyn","family":"Singer","sequence":"additional","affiliation":[{"name":"Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6216-9635","authenticated-orcid":false,"given":"Maria","family":"Theodorakopulou","sequence":"additional","affiliation":[{"name":"Intensive Care Unit, General Hospital of Athens \u201cKAT,\u201d Athens, Greece."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5874-9087","authenticated-orcid":false,"given":"Arzu","family":"Topeli","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Division of Intensive Care, Sepsis Research, Education and Practice Center, Hacettepe University Faculty of Medicine, Ankara, Turkey."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0996-1487","authenticated-orcid":false,"given":"Erin","family":"Barreto","sequence":"additional","affiliation":[{"name":"Department of Pharmacy, Mayo Clinic, Rochester, MN, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0420-0320","authenticated-orcid":false,"given":"Seth R.","family":"Bauer","sequence":"additional","affiliation":[{"name":"Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6564-5200","authenticated-orcid":false,"given":"Laurence W.","family":"Busse","sequence":"additional","affiliation":[{"name":"Department of Medicine, Emory Critical Care Center, Emory Healthcare, Emory University School of Medicine, Atlanta, GA, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2400-3217","authenticated-orcid":false,"given":"Craig M.","family":"Coopersmith","sequence":"additional","affiliation":[{"name":"Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9490-4024","authenticated-orcid":false,"given":"Clifford","family":"Deutschman","sequence":"additional","affiliation":[{"name":"Cohen Children\u2019s Medical Center, The Zucker School of Medicine at Northwell\/Hofstra, The Feinstein Institute for Medical Research, Manhasset, NY, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2635-3923","authenticated-orcid":false,"given":"Andre L.","family":"Holder","sequence":"additional","affiliation":[{"name":"Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory 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Atlanta, GA, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6234-6160","authenticated-orcid":false,"given":"Ryan C.","family":"Maves","sequence":"additional","affiliation":[{"name":"Division of Critical Care Medicine, Department of Anesthesiology, Division of Infectious Diseases, Department of Internal Medicine, Wake Forest University School of Medicine, Winston\u2010Salem, NC, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7550-4751","authenticated-orcid":false,"given":"Lama","family":"Nazer","sequence":"additional","affiliation":[{"name":"King Hussein Cancer Center, Amman, Jordan."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2129-4733","authenticated-orcid":false,"given":"Mark E.","family":"Nunnally","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone 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Research Center, Riyadh, Kingdom of Saudi Arabia."},{"name":"King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3516-9696","authenticated-orcid":false,"given":"Bruno AMP","family":"Besen","sequence":"additional","affiliation":[{"name":"Intensive Care Department, Escola Paulista de Medicina, Universidade Federal de S\u00e3o Paulo, S\u00e3o Paulo, SP, Brazil."},{"name":"D\u2019Or Institute for Research and Education, S\u00e3o Paulo, SP, Brazil."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2798-6263","authenticated-orcid":false,"given":"Alexandre Biasi","family":"Cavalcanti","sequence":"additional","affiliation":[{"name":"Division of Anesthesiology, Hospital das Cl\u00ednicas, Universidade de S\u00e3o Paulo, S\u00e3o Paulo, SP, Brazil."},{"name":"HCor Research Institute, S\u00e3o Paulo, Brazil."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7620-5577","authenticated-orcid":false,"given":"Adam M","family":"Deane","sequence":"additional","affiliation":[{"name":"Department of Critical Care, Melbourne Medical School, & Intensive Care Unit, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2785-5864","authenticated-orcid":false,"given":"Simon","family":"Finfer","sequence":"additional","affiliation":[{"name":"The George Institute for Global Health, University of New South Wales, Sydney, Australia."},{"name":"Faculty of Health, Imperial College London, London, UK."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6559-7747","authenticated-orcid":false,"given":"Naomi","family":"Hammond","sequence":"additional","affiliation":[{"name":"The George Institute for Global Health, University of New South Wales, Sydney, Australia."},{"name":"Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8914-4171","authenticated-orcid":false,"given":"Miguel","family":"Ibarra-Estrada","sequence":"additional","affiliation":[{"name":"Department of Intensive Care Unit, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, M\u00e9xico."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1997-6893","authenticated-orcid":false,"given":"Eduardo","family":"Kattan","sequence":"additional","affiliation":[{"name":"Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Cat\u00f3lica de Chile, Santiago, 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