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Despite timely intervention, there exists a small subgroup of patients with septic shock who develop progressive multi-organ failure. Seemingly refractory to conventional therapy, they exhibit a very high mortality.
Refractory septic shock is variably defined as the presence of hypotension, with end-organ dysfunction, requiring high-dose vasopressor support often greater than 0.5 μg/kg/min norepinephrine or equivalent. Regardless of the precise definition, there is an associated mortality of up to 60%. Furthermore, patients with vasopressor requirements greater than 1 μg/kg/min norepinephrine or equivalent who continue to deteriorate clinically have a reported mortality as high as 80–90%. Microcirculatory failure and associated ischaemic consequences are frequently observed and alternative therapeutic strategies are desperately needed to improve outcomes in this small subgroup of critically ill patients.