Hemodynamic management of septic shock: beyond the Surviving Sepsis Campaign guidelines

Abstract

Although the Surviving Sepsis Campaign guidelines provide standardized and generalized guidance, they are less individualized. This review focuses on recent updates in the hemodynamic management of septic shock. Monitoring and intervention for septic shock should be personalized according to the phase of shock. In the salvage phase, fluid resuscitation and vasopressors should be given to provide life-saving tissue perfusion. During the optimization phase, tissue perfusion should be optimized. In the stabilization and de-escalation phases, minimal fluid infusion and safe fluid removal should be performed, respectively, while preserving organ perfusion. There is controversy surrounding the use of restrictive versus liberal fluid strategies after initial resuscitation. Fluid administration after initial resuscitation should depend upon the patient's fluid responsiveness and requires individualized management. A number of dynamic tests have been proposed to monitor fluid responsiveness, which can help clinicians decide whether to give fluid or not. The optimal timing for the initiation of vasopressor agents is unknown. Recent data suggest that early vasopressor initiation should be considered. Inotropes can be considered in patients with decreased cardiac contractility associated with impaired tissue perfusion despite adequate volume status and arterial blood pressure. Venoarterial extracorporeal membrane oxygenation should be considered for refractory septic shock with severe cardiac systolic dysfunction.

Keywords: Extracorporeal membrane oxygenation; Fluid responsiveness; Resuscitation; Septic shock; Vasopressor agent.

Fig. 1.

Hemodynamic monitoring, targets, and interventions at the different phases of shock. CRT, capillary refill time; MAP, mean arterial pressure; DAP, diastolic arterial pressure; SvO₂, mixed venous oxygen saturation; ScvO₂, central venous oxygen saturation; Pv-aCO₂, venous-to-arterial carbon dioxide difference; TPTD, transpulmonary thermodilution; EVLW, extravascular lung water.

Fig. 2.

Vasoactive agents and their effects.