UMEM Educational Pearls

Category: Critical Care

Title: Hemodynamic Pearls from the Surviving Sepsis Guidelines

Posted: 1/29/2013 by Haney Mallemat, MD (Emailed: 1/30/2013) (Updated: 1/30/2013)
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The updated Surviving Sepsis Guidelines have been released (click here) and here are some recommendations as they pertain to hemodynamic management (grades of recommendations in parenthesis).

Fluid therapy

  • An initial fluid bolus of at least 30 mL/kg is recommended; crystalloids should be the initial fluids (1B).
  • Consider albumin when “substantial” amounts of crystalloid have been given (2C).
  • Use of hydroxyethyl starch is not recommended (1B)

Vasopressors (targeting MAP of at least 65 mmHg)

  • Norepinephrine (NE) is the vasopressor of choice (1B)
  • Epinephrine (EPI) if an additional agent is required; can be added to or substituted for NE (2B)
  • Vasopressin (0.03 units/minute) can be added to NE; it should not be titrated or used as a single agent (ungraded).
  • In selected patients (e.g., bradycardia or low-risk of tachyarrhythmia), dopamine may be considered (2C). Low-dose dopamine (for renal protection) should not be used (1A).
  • Phenylephrine (PE) is not recommended, except if (1C):
    • Serious NE associated arrhythmias
    • Cardiac output can be measured and is increased with low MAP (PE can reduce cardiac output)
    • Other therapies cannot achieve the target MAP


  • Use if fluids and vasopressors cannot restore adequate perfusion
  • Total daily dose of 200 mg (2C) administered by continuous infusion (2D)
  • ACTH stimulation test is not recommended (2B)
  • Tapering hydrocortisone when vasopressors have been discontinued (2D)

Inotropic Therapy

  • Administer dobutamine if it is believed that cardiac filling pressures are elevated, cardiac output is low, or persistent signs of hypoperfusion despite other therapies (1C)


Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock. Crit Care Med. 2013 Feb;41(2):580-637.

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