How is hemodynamic improvement defined, measured, and achieved in sepsis/septic shock?

Updated: Oct 07, 2020
  • Author: Andre Kalil, MD, MPH; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM  more...
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Answer

The 2012 Surviving Sepsis Campaign guidelines recommend rapid administration of an initial fluid challenge with 30 mL/kg of crystalloid solution. [11] Albumin infusion should be used only when substantial amounts of crystalloid solution are required. Hydroxyethyl starch solutions are not recommended.

In some patients, clinical assessment of the response to volume infusion may be difficult. In such cases, it may be facilitated by monitoring the response of CVP or pulmonary artery occlusion pressure (PAOP) to fluid boluses because if either pressure increases, then fluid infusion should be stopped and the patient’s cardiovascular status reassessed. Fluid administration should be continued as long as hemodynamic improvement continues. [11, 60] Hemodynamic improvement is defined as increased organ perfusion, decreasing serum lactate and metabolic acidosis, and improved end-organ function. Fluid responsiveness can be accurately assessed at the bedside using dynamic measures of volume responsiveness, such as pulse pressure or stroke volume variation during positive-pressure breathing or the change in cardiac output to a passive leg-raising maneuver.

A sustained rise of more than 5 mm Hg in cardiac filling pressure after a fluid volume is infused indicates that the compliance of the vascular system is decreasing as further fluid is being infused. Such patients are susceptible to volume overload, and further fluid should be administered with care.


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