If hypotension persists after aggressive fluid resuscitation in septic shock, the next step is:

• A. Increase fluids to 10 L
• B. Administer diuretics
• C. Withhold all therapies
• D. Vasopressor support to maintain mean arterial pressure

Answer: (D)

When septic shock patients remain hypotensive after adequate fluid resuscitation, the immediate step is to start vasopressor therapy to raise mean arterial pressure and preserve organ perfusion. Septic shock causes widespread vasodilation and capillary leak, so fluids alone often cannot sustain the pressure needed to perfuse tissues. Vasopressors, such as norepinephrine, constrict blood vessels and increase systemic vascular resistance, helping to bring MAP up toward a target (typically around 65 mmHg, though individual goals may vary). This supports kidney function, brain perfusion, and other vital organs while fluids are continued as needed to optimize preload.

Avoid escalating fluids to extreme volumes, as excessive administration can worsen edema and tissue edema without reliably improving pressure once vasodilation is established. Withholding therapies would neglect the primary mechanism driving hypotension, and diuretics would reduce circulating volume further, worsening perfusion.

In practice, monitor arterial pressure to ensure MAP remains adequate, assess perfusion indicators such as urine output and lactate, and titrate the vasopressor dose to achieve the target MAP while watching for side effects like tissue ischemia or arrhythmias.