Mixed shock: from pathophysiology to clinical practice

Mixed shock represents a complex haemodynamic entity arising from a variable combination of impaired contractility and vasoplegia. Its clinical recognition is challenging, as it may appear as an intermediate state in the evolution of cardiogenic or distributive shock, or result from the simultaneous coexistence of distinct pathophysiological mechanisms. Neurohormonal activation, which is common across both ends of the shock spectrum, contributes to fluid retention and further deterioration of circulatory function. Although pathophysiological interpretation is essential to guide management, it may be constrained by the temporal overlap of haemodynamic events. In clinical practice, the optimal approach integrates goal-directed haemodynamic correction with continuous bedside assessment of tissue perfusion. Pharmacological selection should account for the interaction between myocardial contractility and vascular tone, prioritising agents with combined or complementary effects. In this context, clinical judgement grounded in a sound understanding of pathophysiology remains the decisive tool in the management of mixed shock.