From: A plea for personalization of the hemodynamic management of septic shock
Phase of shock | Purpose | Targets | Interventions | Monitoring tools |
---|---|---|---|---|
Salvage | *Perform life-saving measures | *Maintain minimal MAP and CO | *Fluids *Vasopressors according to MAP and DAP | *Arterial pressure (often noninvasive, turn to invasive if not responding) *CRT *Lactate |
 | *Identify shock |  |  | *Clinical examination *Arterial pressure *Lactate |
 | *Identify severe cardiac dysfunction |  |  | *Echocardiography *CRT *Jugular vein distension |
Optimization | Â | Â | Â | Â |
Initial | *Optimize tissue perfusion | *Normalize indices of tissue perfusion *Optimize MAP *Optimize CO | *Fluids according to fluid responsiveness and tolerance *Vasopressors *Inotropes according to CO and echocardiography | *CRT *Lactate *CVP – ScvO2-PvaCO2 *Urine output *Minimally invasive CO *Echocardiography if not yet performed *Evaluation of fluid responsiveness |
Subsequent (if not responding to initial) | *Optimize tissue perfusion | *Normalize indices of tissue perfusion *Optimize MAP *Optimize CO | *Fluids according to fluid responsiveness and tolerance *Vasopressors *Inotropes according to CO and echocardiography | *CRT *Lactate *CVP – ScvO2-PvaCO2 *Urine output *Evaluation of fluid responsiveness *Advanced hemodynamic monitoring (TPTD or PAC ± Echocardiography) *Venous ultrasounds |
Stabilization | *Provide organ support *Minimize complications | *Preserve organ perfusion *Limit exposure to fluids, vasopressors and inotropes, if possible *Limit impact of accumulated fluids | *Avoid fluids unless absolutely needed, if possible consider fluid removal *Lowest dose of vasopressors to achieve target MAP *Lowest dose of inotropes to maintain target CO | *Maintain existing monitoring *EVLW (TPTD or lung ultrasound) *Venous stasis |
De-escalation | *De-escalate engaged therapies while avoiding impairment in tissue perfusion | *Achieve negative fluid balance *Wean vasopressors *Wean inotropes *Preserve tissue perfusion | *Fluid removal by diuretics and/or mechanical *Wean vasopressors if MAP preserved *Wean inotropes if acceptable CO preserved | * Arterial pressure (often noninvasive) *Minimal or no CO-monitoring at this stage *Evaluate fluid responsiveness prior to fluid removal *Evaluate tissue perfusion *Lactate |