Initial resuscitation from severe sepsis: one size does not fit all.

Over recent decades many recommendations for the management of patients with sepsis and septic shock have been published, mainly as the Surviving Sepsis Campaign (SSC) guidelines. In order to use these recommendations at the bedside one must fully understand their limitations, especially with regard to preload assessment, fluid responsiveness and cardiac output. In this review we will discuss the evidence behind the bundles presented by the Surviving Sepsis Campaign and will try to explain why some recommendations may need to be updated. Barometric preload indicators, such as central venous pressure (CVP) or pulmonary artery occlusion pressure, can be persistently low or erroneously increased, as is the case in situations of increased intrathoracic pressure, as seen with the application of high positive end-expiratory pressure, or in situations with increased intra-abdominal pressure. Chasing a CVP of 8 to 12 mm Hg may lead to under-resuscitation in these situations. On the other hand, a low CVP does not always correspond to fluid responsiveness and may lead to over-resuscitation and all the deleterious effects on end-organ function associated with fluid overload. We will suggest the introduction of new variables and more dynamic measurements. During the initial resuscitation phase, it is equally important to assess fluid responsiveness, either with a passive leg raising manoeuvre or an end-expiratory occlusion test. The use of functional hemodynamics with stroke volume variation or pulse pressure variation may further help to identify patients who will respond to fluid administration or not. Furthermore, ongoing fluid resuscitation beyond the first 24 hours guided by CVP may lead to futile fluid loading. In patients that do not transgress spontaneously from the Ebb to Flow phase of shock, one should consider (active) de-resuscitation guided by extravascular lung water index measurements.