In this episode of the FlightBridgeED MDCast, Dr. Mike Lauria and Dr. Brittany Bernardoni discuss the management of refractory hypotension in septic patients. They explore the use of norepinephrine as the initial pressor of choice and the benefits of vasopressin as a second-line agent. They also discuss the use of inotropes, such as epinephrine and dobutamine, and the importance of assessing cardiac function with ultrasound. The conversation provides practical guidance for managing hypotensive septic patients in various clinical settings. In this conversation, the hosts discuss the use of different therapies for refractory shock and sepsis. They cover topics such as pressors, fluid resuscitation, steroids, bicarbonate, calcium, and all levels of therapies. Mike and Brittany provide insight into the evidence-based use of these therapies and offer practical tips for their administration in the hospital and in the critical care transport medicine field. Overall, the conversation provides a comprehensive overview of refractory shock and sepsis management. Key Takeaways to Pay Attention to During This Discussion Mean arterial pressure (MAP) is the best number to assess hypotension, with a goal of MAP > 65.Norepinephrine is the workhorse pressor for septic patients, providing both venous and arterial constriction.Vasopressin is a valuable second-line agent, especially for patients with right heart dysfunction or acidosis.There is no maximum dose for norepinephrine, but doses above 2.0 mcg/kg/min may not provide additional benefit.Ultrasound assessment of cardiac function is crucial in determining the need for inotropes.Epinephrine is the preferred inotrope due to its increased squeeze and peripheral vasoconstriction.Dobutamine is not commonly used in vasoplegic shock due to its peripheral vasodilation effects. Pressors such as norepinephrine are the first-line therapy for refractory shock and sepsis.Steroids, specifically hydrocortisone, can be considered in patients on norepinephrine more than 0.25.Bicarbonate can be used to increase pH, but caution must be taken to ensure proper ventilation.Calcium chloride or calcium gluconate can be used to address low calcium levels.In refractory cases, level three therapies, such as angiotensin 2, methylene blue, and cyanocid, may be considered.