Septic Shock Fluid Resuscitation Strategy: Consensus and Controversy Coexist, Exploring the Optimal Approach

Septic shock, a life-threatening condition resulting from an uncontrolled host response to infection, poses a significant threat to human health. Despite advances in basic research and clinical treatment, the mortality rate of septic shock remains high, around 40%. Effective fluid resuscitation plays a crucial role in managing septic shock patients.

From a pathophysiological perspective, optimal blood flow dynamics rely on adequate circulating volume (preload), cardiac function (pump), and vascular tone (afterload). Septic shock is characterized by distributive shock, with widespread vasodilation and decreased afterload, as well as decreased effective circulating blood volume due to microvascular leak and fluid loss. Approximately 50% of patients also experience septic cardiomyopathy.

The goal of fluid resuscitation is to increase effective circulating blood volume, enhance cardiac output, and improve oxygen delivery. However, the optimal approach to fluid resuscitation remains debated. Early Goal-Directed Therapy (EGDT) was initially recommended, but subsequent studies found no significant reduction in mortality rates and increased adverse effects due to fluid overload.

Currently, a staged approach to fluid resuscitation is adopted, with initial aggressive crystalloid resuscitation (30 mL/kg in the first 3 hours) followed by restrictive fluid management. The choice of fluid and vasopressor agents is also crucial. Norepinephrine is recommended as the first-line vasopressor, with dopamine and dobutamine reserved for specific patients.

Assessing fluid responsiveness is essential, with various methods available, including central venous pressure (CVP), pulse pressure variation (PPV), stroke volume variation (SVV), and passive leg raising (PLR) tests. However, each method has its limitations, and a combination of parameters is often used.

Regarding the endpoint of fluid resuscitation, no gold standard exists. Clinicians often combine markers of tissue perfusion and blood flow dynamics. Central venous oxygen saturation (ScvO2) is used as a marker of tissue reperfusion, with a target value ≥ 0.7. However, its application is limited by various factors, and a single parameter is not sufficient.

In conclusion, the optimal fluid resuscitation strategy for septic shock patients remains a topic of debate. Clinicians should adopt an individualized, staged approach, considering the patient's pathophysiological characteristics and blood flow dynamics. By exploring the optimal approach to fluid resuscitation, we can improve the prognosis of septic shock patients and provide them with more hope for survival.