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Table 1 Targets and monitoring techniques at the different phases of shock

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

    

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

  1. MAP mean arterial pressure, DAP diastolic arterial pressure, CO cardiac output, CRT capillary refill time, CVP central venous pressure, ScvO2 central venous pressure, PvaCO2 veno-arterial difference in PCO2, EVLW extravascular lung water, TPTD transpulmonary thermodilution, PAC pulmonary artery catheter