Hemodynamic management of septic shock: Beyond of the SSC guidelines

Although the SSC Guidelines provide a 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 tissue perfusion for life-saving. 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 a controversy on the use of restrictive versus liberal fluid strategies after initial resuscitation. Fluid administration after initial resuscitation should depend on the patient's fluid responsiveness and require individualized management. A number of dynamic tests have been proposed to monitor fluid responsiveness, which help clinicians decide whether to give fluid or not. The optimal timing for the initiation of vasopressors 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. Veno-arterial ECMO should be considered for refractory septic shock with severe cardiac systolic dysfunction.