What is your threshold to start stress dose steroids in the management of patients with septic shock?  

Absent long-term use at baseline, I do not routinely start stress dose steroids for patients with septic shock. I reserve steroids for patients with a persistent vasopressor requirement despite adequate volume resuscitation and treatment of the underlying source of infection.

I completely agree. Refractory shock is the main indication for my use; specifically when a patient is on 2 pressors without improvement despite adequate resuscitation. As an example; when using norepinephrine, I add vasopressin once the dose is above 0.2 mcg/kg/minute (20 mcg/minute). If the shoc...