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Table 4 Hemodynamics in early septic shock

From: Hemodynamic support in the early phase of septic shock: a review of challenges and unanswered questions

Main questions Actual recommendations* Unanswered questions
Which MAP targets to stabilize the macrocirculation? MAP ≥ 65 mmHg What is the best timing for MAP intervention in sepsis? and until when?
Could “permissive hypotension” be considered as in the case of trauma? for which reason(s) and target(s)?
How much fluid resuscitation and when? From “time of presentation” or “time zero,” 30 mL/kg at least within 1 h Should we prioritize fixed minimum fluid resuscitation or dynamic personalized reassessment of circulation status?
Which fluid(s)? Crystalloids Beyond balanced versus unbalanced crystalloid fluid selection, should we prefer acetate- or lactate-buffered solutions?
How long? After the initial 1-h interventions, further fluid administration needs patients’ assessment for responsiveness What “gauge for a filled tank”?
Which vasoactive (± inotropic) drug(s)? NE is recommended as a 1st choice vasopressor. AVP or E can be added to help reaching the target (i.e., MAP) and spare NE Within a “hour-1 bundle” strategy, should we trade-off less fluids and more vasoactive drugs to vice versa?
When? Dobutamine only if target not reached after adequate fluid loading and use of vasoactive drugs Are vasopressor combinations able to reach high MAP levels without detrimental cardiac side effects?
  As early as during the initial fluid resuscitation period, to achieve the target MAP ≥ 65 mmHg ASAP With NE as the currently recommended first-line vasopressor is “decatecholaminization” feasible and safe?
  1. MAP mean arterial pressure, NE norepinephrine, AVP arginine vasopressin, E epinephrine, ASAP as soon as possible
  2. *According to the Surviving Sepsis Campaign 2016 and the 2018 update (Refs [3, 4])