From a pressure-guided to a perfusion-centered resuscitation strategy in septic shock: Critical literature review and illustrative case

To support a paradigm shift in the management of septic shock from pressure-guided to perfusion-centered, expected to improve outcome while reducing adverse effects from vasopressor therapy and aggressive fluid resuscitation. Critical review of the literature cited in support of vasopressor use to achieve a predefined mean arterial pressure (MAP) of 65 mmHg and review of pertinent clinical trials and studies enabling deeper understanding of the hemodynamic pathophysiology supportive of a perfusion-centered approach, accompanied by an illustrative case. Review of the literature cited by the Surviving Sepsis Campaign revealed lack of controlled clinical trials supporting outcome benefits from vasopressors. Additional literature review revealed adverse effects associated with vasopressors and worsened outcome in some studies. Vasopressors increase MAP primarily by peripheral vasoconstriction and in occasions by a modest increase in cardiac output when using norepinephrine. Thus, achieving the recommended MAP of 65 mmHg using vasopressors should not be presumed indicative that organ perfusion has been restored. It may instead create a false sense of hemodynamic stability hampering shock resolution. We propose focusing the hemodynamic management of septic shock on reversing organ hypoperfusion instead of attaining a predefined MAP target as the key strategy for improving outcome. •Controlled studies supporting outcome benefits from vasopressor therapy are lacking.•Vasopressors (especially adrenergic agents) elicit multiple adverse effect.•Vasopressors target arterioles increasing blood pressure predominantly by vasoconstriction.•Vasopressors may exert a mild to moderate effect on cardiac output.•A shift from pressure-guided to perfusion-centered resuscitation is proposed as key strategy to improve septic shock outcome.