Skip to main content
Log in

Hemodynamic management of septic shock

  • Published:
Current Infectious Disease Reports Aims and scope Submit manuscript

Abstract

Septic shock is characterized by profound cardiovascular alterations, including hypovolemia, severe alterations in vascular tone, and myocardial depression. These effects can lead to tissue hypoperfusion, the persistence of which could contribute to multiple organ failure. In addition, regional blood flow alterations and microvascular blood flow alterations may coexist and persist even after whole body hemodynamic alterations are corrected. Early aggressive interventions to improve oxygen delivery have been shown to improve outcome, but ongoing hemodynamic support is often required. This review will examine the hemodynamic management of patients with septic shock.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. Singer M, De S, V, Vitale D, et al.: Multiorgan failure is an adaptive, endocrine-mediated, metabolic response to overwhelming systemic inflammation. Lancet 2004, 364:545–548.

    Article  PubMed  Google Scholar 

  2. Brealey D, Brand M, Hargreaves I, et al.: Association between mitochondrial dysfunction and severity and outcome of septic shock. Lancet 2002, 360:219–223.

    Article  PubMed  CAS  Google Scholar 

  3. Hollenberg SM, Cunnion RE, Parrillo JE: Effect of septic serum on vascular smooth muscle: In vitro studies using rat aortic rings. Crit Care Med 1992, 20:993–998.

    Article  PubMed  CAS  Google Scholar 

  4. Landin L, Lorente JA, Renes E, et al.: Inhibition of nitric oxide synthesis improves the vasoconstrictive effects of noradrenaline in sepsis. Chest 1994, 106:250–256.

    PubMed  CAS  Google Scholar 

  5. Pastor CM and Billiar TR: Nitric oxide causes hyporeactivity to phenylephrine in isolated perfused livers from endotoxintreated rats. Am J Physiol 1995, 268:G177-G182.

    PubMed  CAS  Google Scholar 

  6. Landry DW, Levin HR, Gallant EM, et al.: Vasopressin deficiency contributes to the vasodilation of septic shock. Circulation 1997, 95:1122–1125.

    PubMed  CAS  Google Scholar 

  7. Sharshar T, Blanchard A, Paillard M, et al.: Circulating vasopressin levels in septic shock. Crit Care Med 2003, 31:1752–1758.

    Article  PubMed  CAS  Google Scholar 

  8. Roth BL and Spitzer JA.: Altered hepatic vasopressin and alpha 1-adrenergic receptors after chronic endotoxin infusion. Am J Physiol 1987, 252:E699-E702.

    PubMed  CAS  Google Scholar 

  9. Hollenberg SM, Tangora JJ, Piotrowski MJ, et al.: Impaired microvascular vasoconstrictive responses to vasopressin in septic rats. Crit Care Med 1997, 25:869–873.

    Article  PubMed  CAS  Google Scholar 

  10. Pinsky MR and Matuschak GM: Cardiovascular determinants of the hemodynamic response to acute endotoxemia in the dog. J Crit Care 1986, 1:18–31.

    Article  Google Scholar 

  11. Ayuse T, Brienza N, Revelly JP, et al.: Alterations in liver hemodynamics in an intact porcine model of endotoxin shock. Am J Physiol 1995, 268:H1106-H1114.

    PubMed  CAS  Google Scholar 

  12. O’Dwyer ST, Michie HR, Ziegler TR, et al.: A single dose of endotoxin increases intestinal permeability in healthy humans. Arch Surg 1988, 123:1459–1464.

    PubMed  CAS  Google Scholar 

  13. Fink MP, Antonsson JB, Wang H, et al.: Increased intestinal permeability in endotoxic pigs. Arch Surg 1991, 126:211–218.

    PubMed  CAS  Google Scholar 

  14. Stephan F, Novara A, Tournier B, et al.: Determination of total effective vascular compliance in patients with sepsis syndrome. Am J Respir Crit Care Med 1998, 157:50–56.

    PubMed  CAS  Google Scholar 

  15. Suffredini AF, Fromm RE, Parker MM, et al.: The cardiovascular response of normal humans to the administration of endotoxin. N Engl J Med 1989, 321:280–287.

    Article  PubMed  CAS  Google Scholar 

  16. Nelson DP, Beyer C, Samsel RW, et al.: Pathological supply dependence of O2 uptake during bacteremia in dogs. J Appl Physiol 1987, 63:1487–1492.

    PubMed  CAS  Google Scholar 

  17. Zhang H, Smail N, Cabral A, et al.: Hepato-splanchnic blood flow and oxygen extraction capabilities during experimental tamponade: effects of endotoxin. J Surg Res 1999, 81:129–138.

    Article  PubMed  CAS  Google Scholar 

  18. Ellis CG, Bateman RM, Sharpe MD, et al.: Effect of a maldistribution of microvascular blood flow on capillary O(2) extraction in sepsis. Am J Physiol 2002, 282:H156-H164.

    CAS  Google Scholar 

  19. Vincent JL and De Backer D: Oxygen transport—the oxygen delivery controversy. Intensive Care Med 2004, 30:1990–1996.

    Article  PubMed  Google Scholar 

  20. Sun Q, Tu Z, Lobo S, et al.: Optimal adrenergic support in septic shock due to peritonitis. Anesthesiology 2003, 98:888–896.

    Article  PubMed  CAS  Google Scholar 

  21. Bernardin G, Pradier C, Tiger F, et al.: Blood pressure and arterial lactate level are early indicators of short-term survival in human septic shock. Intensive Care Med 1996, 22:7–25.

    Article  Google Scholar 

  22. Levy B, Dusang B, Annane D, et al.: Cardiovascular response to dopamine and early prediction of outcome. A prospective multicenter study. Crit Care Med 2005, 33:2172–2177.

    Article  PubMed  CAS  Google Scholar 

  23. Abid O, Akca S, Haji-Michael P, et al.: Strong vasopressor support may be futile in the intensive care unit patient with multiple organ failure. Crit Care Med 2000, 28:947–949.

    Article  PubMed  CAS  Google Scholar 

  24. Varpula M, Tallgren M, Saukkonen K, et al.: Hemodynamic variables related to outcome in septic shock. Intensive Care Med 2005, 31:1066–1071. Hemodynamic variables were continuously recorded in 111 consecutive patients with septic shock. The authors reported that time spent under a mean arterial pressure of 65 mm Hg and under a mixed venous oxygen saturation of 70% were major determinants of a poor outcome.

    Article  PubMed  Google Scholar 

  25. LeDoux D, Astiz ME, Carpati CM, et al.: Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med 2000, 28:2729–2732.

    Article  PubMed  CAS  Google Scholar 

  26. Bourgoin A, Leone M, Delmas A, et al.: Increasing mean arterial pressure in patients with septic shock: effects on oxygen variables and renal function. Crit Care Med 2005, 33:780–786. Small, randomized controlled trial investigating the impact of two levels of arterial pressure on renal function.

    Article  PubMed  CAS  Google Scholar 

  27. Cholley BP, Lang RM, Berger DS, et al.: Alterations in systemic arterial mechanical properties during septic shock: role of fluid resuscitation. Am J Physiol 1995, 269:H375-H384.

    PubMed  CAS  Google Scholar 

  28. De Backer D, Zhang H, Cherkhaoui S, et al.: Effects of dobutamine on hepato-splanchnic hemodynamics in an experimental model of hyperdynamic endotoxic shock. Shock 2001, 15:208–214.

    Article  PubMed  Google Scholar 

  29. Shoemaker WC, Appel PL, Kram HB, et al.: Sequence of physiologic patterns in surgical septic shock. Crit Care Med 1993, 21:1876–1889.

    Article  PubMed  CAS  Google Scholar 

  30. Shoemaker WC, Appel PL, Kram HB, et al.: Temporal hemodynamic and oxygen transport patterns in medical patients: septic shock. Chest 1993, 104:1529–1536.

    PubMed  CAS  Google Scholar 

  31. Tuchschmidt J, Fried J, Astiz M, et al.: Elevation of cardiac output and oxygen delivery improves outcome in septic shock. Chest 1992, 102:216–220.

    PubMed  CAS  Google Scholar 

  32. Mythen MG and Webb AR.: The role of gut mucosal hypoperfusion in the pathogenesis of post-operative organ dysfunction. Intensive Care Med 1994, 20:203–209.

    Article  PubMed  CAS  Google Scholar 

  33. Poeze M, Solberg BC, Greve JW, et al.: Monitoring global volume-related hemodynamic or regional variables after initial resuscitation: What is a better predictor of outcome in critically ill septic patients? Crit Care Med 2005, 33:2494–2500. In this small observational study, the authors reported that at the initial phase both global and regional indices of perfusion were associated with outcome. After initial resuscitation, though, the alterations in regional perfusion were strong predictors of a poor outcome.

    Article  PubMed  Google Scholar 

  34. Gutierrez G, Palizas F, Doglio G, et al.: Gastric intramucosal pH as a therapeutic index of tissue oxygenation in critically ill patients. Lancet 1992, 339:195–199.

    Article  PubMed  CAS  Google Scholar 

  35. Gomersall CD, Joynt GM, Freebairn RC, et al.: Resuscitation of critically ill patients based on the results of gastric tonometry: a prospective, randomized, controlled trial. Crit Care Med 2000, 28:607–614.

    Article  PubMed  CAS  Google Scholar 

  36. Schrier RW and Wang W.: Acute renal failure and sepsis. N Engl J Med 2004, 351:159–169.

    Article  PubMed  CAS  Google Scholar 

  37. Langenberg C, Bellomo R, May C, et al.: Renal blood flow in sepsis. Crit Care 2005, 9:R363-R374. Interesting review evaluating renal blood flow measurements in various experimental models of sepsis.

    Article  PubMed  Google Scholar 

  38. Baker CH and Wilmoth FR.: Microvascular responses to E. coli endotoxin with altered adrenergic activity. Circ Shock 1984, 12:165–176.

    PubMed  CAS  Google Scholar 

  39. Lam CJ, Tyml K, Martin CM, et al.: Microvascular perfusion is impaired in a rat model of normotensive sepsis. J Clin Invest 1994, 94:2077–2083.

    Article  PubMed  CAS  Google Scholar 

  40. Farquhar I, Martin CM, Lam C, et al.: Decreased capillary density in vivo in bowel mucosa of rats with normotensive sepsis. J Surg Res 1996, 61:190–196.

    Article  PubMed  CAS  Google Scholar 

  41. McCuskey RS, Urbaschek R, and Urbaschek B.: The microcirculation during endotoxemia. Cardiovasc Res 1996, 32:752–763.

    Article  PubMed  CAS  Google Scholar 

  42. De Backer D, Creteur J, Preiser JC, et al.: Microvascular blood flow is altered in patients with sepsis. Am J Respir Crit Care Med 2002, 166:98–104.

    Article  PubMed  Google Scholar 

  43. Sakr Y, Dubois MJ, De Backer D, et al.: Persistent microvasculatory alterations are associated with organ failure and death in patients with septic shock. Crit Care Med 2004, 32:1825–1831.

    Article  PubMed  Google Scholar 

  44. Rivers E, Nguyen B, Havstadt S, et al.: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001, 345:1368–1377.

    Article  PubMed  CAS  Google Scholar 

  45. Hollenberg SM, Dumasius A, Easington C, et al.: Characterization of a hyperdynamic murine model of resuscitated sepsis using echocardiography. Am J Respir Crit Care Med 2001, 164:891–895.

    PubMed  CAS  Google Scholar 

  46. Gattinoni L, Brazzi L, Pelosi P, et al.: A trial of goal-oriented hemodynamic therapy in critically ill patients. N Engl J Med 1995, 333:1025–1032.

    Article  PubMed  CAS  Google Scholar 

  47. Vincent JL and Weil MH: Fluid challenge revisited. Crit Care Med 2006, 34:1333–1337. Interesting review of how to conduct a fluid challenge.

    Article  PubMed  Google Scholar 

  48. Finfer S, Bellomo R, Boyce N, et al.: A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004, 350:2247–2256.

    Article  PubMed  CAS  Google Scholar 

  49. Sakr Y, Reinhart K, Vincent JL, et al.: Does dopamine administration in shock influence outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study. Crit Care Med 2006, 34:589–597. Large observational study on a European database. The authors describe the current use of vasopressor agents in different countries and the potential negative impact of dopamine on outcome.

    Article  PubMed  CAS  Google Scholar 

  50. Lopez A, Lorente JA, Steingrub J, et al.: Multiple-center, randomized, placebo-controlled, double-blind study of the nitric oxide synthase inhibitor 546C88: effect on survival in patients with septic shock. Crit Care Med 2004, 32:21–30.

    Article  PubMed  CAS  Google Scholar 

  51. Sun Q, Dimopoulos G, Nguyen DN, et al.: Low dose vasopressin in the treatment of septic shock in sheep. Am J Respir Crit Care Med 2003, 168:481–486.

    Article  PubMed  Google Scholar 

  52. Patel BM, Chittock DR, Russell JA, et al.: Beneficial effects of short-term vasopressin infusion during severe septic shock. Anesthesiology 2002, 96:576–582.

    Article  PubMed  CAS  Google Scholar 

  53. Luckner G, Dunser MW, Jochberger S, et al.: Arginine vasopressin in 316 patients with advanced vasodilatory shock. Crit Care Med 2005, 33:2659–2666.

    Article  PubMed  CAS  Google Scholar 

  54. Annane D, Bellissant E, Sebille V, et al.: Impaired pressor sensitivity to noradrenaline in septic shock patients with and without impaired adrenal function reserve. Br J Clin Pharmacol 1998, 46:589–597.

    Article  PubMed  CAS  Google Scholar 

  55. Annane D, Sebille V, Charpentier C, et al.: Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002, 288:862–871.

    Article  PubMed  CAS  Google Scholar 

  56. Trager K, De Backer D, and Radermacher P.: Metabolic alterations in sepsis and vasoactive drug-related metabolic effects. Curr Opin Crit Care 2003, 9:271–278.

    Article  PubMed  Google Scholar 

  57. De Backer D, Creteur J, Dubois MJ, et al.: The effects of dobutamine on microcirculatory alterations in patients with septic shock are independent of its systemic effects. Crit Care Med 2006, 34:403–408. Small interventional study demonstrating the absence of a link between whole body hemodynamics and microvascular blood flow. The dobutamine-induced improvement in microvascular blood flow was associated with signs of improvement of tissue perfusion.

    Article  PubMed  Google Scholar 

  58. Spronk PE, Ince C, Gardien MJ, et al.: Nitroglycerin in septic shock after intravascular volume resuscitation. Lancet 2002, 360:1395–1396.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Daniel De Backer MD, PhD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

De Backer, D. Hemodynamic management of septic shock. Curr Infect Dis Rep 8, 366–372 (2006). https://doi.org/10.1007/s11908-006-0047-z

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11908-006-0047-z

Keywords

Navigation