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

Abstract

Although the Surviving Sepsis Campaign guidelines provide standardized and generalized guid-ance, 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 personal-ized 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 per -fusion 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 resusci-tation. Fluid administration after initial resuscitation should depend upon the patient's fluid re-sponsiveness 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 sug-gest that early vasopressor initiation should be considered. Inotropes can be considered in pa-tients with decreased cardiac contractility associated with impaired tissue perfusion despite ade-quate volume status and arterial blood pressure. Venoarterial extracorporeal membrane oxygen-ation should be considered for refractory septic shock with severe cardiac systolic dysfunction.