• Raúl J Gazmuri and Cristina Añez de Gomez.
• Medicine, Physiology & Biophysics, Resuscitation Institute at Rosalind Franklin University of Medicine and Science, Critical Care Medicine and ICU, Captain James A. Lovell Federal Health Care Center, USA. Electronic address: raul.gazmuri@rosalindfranklin.edu.
• J Crit Care. 2020 Apr 1; 56: 294-304.

PurposeTo 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.Material And MethodsCritical 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.ResultsReview 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.ConclusionsWe 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.Published by Elsevier Inc.

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