What is the next step to restore blood pressure in a patient with septic shock after initial crystalloid fluid resuscitation?

From the Guidelines

The next step to restore blood pressure in a patient with septic shock after initial crystalloid fluid resuscitation is to initiate vasopressor therapy.

Key Considerations

• The initial target mean arterial pressure (MAP) should be 65 mm Hg 1.
• Norepinephrine is recommended as the first-choice vasopressor 1.
• Additional fluids should be guided by frequent reassessment of hemodynamic status 1.

Vasopressor Therapy

• Norepinephrine is the preferred initial vasopressor, with a strong recommendation and moderate quality of evidence 1.
• Vasopressin (up to 0.03 U/min) or epinephrine may be added to norepinephrine to raise MAP or decrease norepinephrine dosage, with a weak recommendation and moderate or low quality of evidence, respectively 1.
• Dopamine may be considered as an alternative vasopressor in highly selected patients, with a weak recommendation and low quality of evidence 1.

Fluid Resuscitation

• Crystalloids are the fluid of choice for initial resuscitation and subsequent intravascular volume replacement, with a strong recommendation and moderate quality of evidence 1.
• Balanced crystalloids or saline may be used for fluid resuscitation, with a weak recommendation and low quality of evidence 1.
• Albumin may be added to crystalloids for initial resuscitation and subsequent intravascular volume replacement when substantial amounts of crystalloids are required, with a weak recommendation and low quality of evidence 1.

From the Research

Next Steps in Restoring Blood Pressure

After initial crystalloid fluid resuscitation in a patient with septic shock, the next steps to restore blood pressure include:

• Administering vasopressors to maintain target mean arterial pressure, as delays in diagnosis and treatment of septic shock are associated with increased risk of mortality 2
• Using dynamic variables of fluid responsiveness to guide further fluid administration after an initial infusion of 30 mL/kg during the first three hours of resuscitation 3
• Considering the use of balanced crystalloids, albumin solutions, or other types of fluids for resuscitation, while avoiding hydroxyethyl starches due to increased risk of acute renal failure and mortality 4
• Instituting invasive hemodynamic monitoring and using vasopressor agents such as dopamine or norepinephrine if the patient remains hypotensive after adequate volume resuscitation 5
• Potentially adopting a more conservative fluid strategy coupled with earlier introduction of vasopressors for hemodynamic support, although this approach is still being studied and debated 6

Key Considerations

• The optimal balance of fluids and vasopressors to maintain target mean arterial pressure is still a topic of controversy and ongoing research 2, 3, 6
• Early and effective fluid resuscitation and vasopressor administration are crucial in maintaining tissue perfusion in septic shock patients 2
• The choice of fluid type and the need for individualization in fluid resuscitation are important considerations in the management of septic shock 3, 4