SSC 2026 — Part 3: Hemodynamic Management

This section covers hemodynamic management of adults with sepsis and septic shock, including blood pressure monitoring modality, fluid type selection (crystalloids, balanced solutions, albumin, starches, gelatin), liberal versus restrictive fluid strategies, dynamic measures of fluid responsiveness, cardiac output monitoring, serial lactate measurement, capillary refill time-guided resuscitation, vasopressor selection and sequencing (norepinephrine, vasopressin, epinephrine, angiotensin II), inotrope use, methylene blue, midodrine, and beta-blockers.

Hemodynamic management in sepsis and septic shock is a cornerstone of critical care practice. The 2026 SSC guidelines provide updated recommendations reflecting evidence from several landmark trials published since 2021, including EVERDAC, ANDROMEDA-SHOCK-2, and updated network meta-analyses of vasopressor and inotrope strategies.

1. Blood Pressure Monitoring

Recommendation 42 — Invasive vs. Noninvasive Blood Pressure Monitoring

For adults with septic shock on vasopressors, we suggest using either invasive or noninvasive blood pressure monitoring.

Conditional recommendation, very low certainty evidence

Change from 2021: Revisited.

Rationale: Invasive arterial blood pressure monitoring via an arterial catheter has traditionally been considered the gold standard for hemodynamic monitoring in patients with septic shock receiving vasopressors. Noninvasive monitoring using oscillometric or continuous noninvasive techniques offers an alternative that avoids procedural complications and may facilitate earlier vasopressor initiation.

At the time of guideline development, the panel found very low certainty evidence and was unable to recommend one monitoring modality over the other. The EVERDAC randomized controlled trial, published after guideline finalization, compared a noninvasive blood pressure monitoring strategy with an invasive strategy in 2,463 patients with septic shock receiving vasopressors. The noninvasive strategy was noninferior to the invasive strategy for 28-day mortality (34.3% vs. 36.9%; absolute difference -2.6%; 95% CI, -6.5% to 1.3%).

“In our practice”: 62.7% of panelists use invasive monitoring for patients on vasopressors.

Remark: Invasive arterial blood pressure monitoring is advised for patients on intermediate-to-high dose vasopressors, those with escalating vasopressor doses, patients receiving multiple vasopressors, situations requiring frequent arterial blood sampling, or when noninvasive measurements are inconsistent or unreliable.

Key considerations for monitoring modality selection:

2. Fluid Type

Recommendation 43 — Crystalloids as First-Line Fluid

For adults with sepsis or septic shock, we recommend using crystalloids as the first-line fluid for resuscitation.

Strong recommendation, moderate certainty evidence

Change from 2021: Carryover.

Rationale: This statement was carried over; please see the 2021 SSC guidelines for rationale.¹ Crystalloid solutions remain the standard first-line resuscitation fluid for sepsis and septic shock due to their widespread availability, low cost, favorable safety profile, and absence of evidence supporting superiority of any alternative fluid class for initial resuscitation.

Recommendation 44 — Balanced Crystalloids vs. 0.9% Saline

For adults with sepsis or septic shock, we suggest using balanced crystalloids over 0.9% saline for fluid resuscitation.

Conditional recommendation, moderate certainty evidence

Change from 2021: Revisited.

Rationale: The choice between balanced crystalloids (e.g., Ringer’s lactate, Plasma-Lyte) and 0.9% saline (normal saline) has been a major area of investigation. 0.9% saline has a supraphysiologic chloride concentration (154 mmol/L vs. plasma 96–106 mmol/L) that may contribute to hyperchloremic metabolic acidosis, renal vasoconstriction, and acute kidney injury.

Three major RCTs have informed this recommendation:

A systematic review and meta-analysis incorporating these and other trials found that balanced crystalloids probably reduced mortality compared with 0.9% saline (OR 0.94; 95% CI, 0.85–1.04) and resulted in a reduction in the need for new renal replacement therapy (OR 0.86; 95% CI, 0.74–0.99, high certainty evidence).

Remark: For patients with sepsis and concomitant traumatic brain injury, the panel suggests using 0.9% saline over balanced crystalloids. Hypotonic balanced solutions may exacerbate cerebral edema and worsen intracranial pressure in this population.

Recommendation 45 — Crystalloids Alone vs. Crystalloids with Supplemental Albumin

For adults with sepsis or septic shock, we suggest using crystalloids alone over crystalloids with supplemental albumin for fluid resuscitation.

Conditional recommendation, moderate certainty evidence

Change from 2021: Revisited.

Rationale: Albumin is a natural colloid that may theoretically provide more sustained intravascular volume expansion than crystalloids. However, it is substantially more expensive and requires specific manufacturing and storage conditions.

The panel reviewed six RCTs involving 4,383 patients, including the ALBIOS and SAFE trials. Supplemental albumin probably had no effect on 28-day mortality compared with crystalloids alone (RR 1.01; 95% CI, 0.90–1.14, moderate certainty). There was no significant difference in other patient-important outcomes.

Remark: Supplemental albumin may be appropriate on a case-by-case basis for patients who have already received large crystalloid volumes or for patients with cirrhosis and sepsis, where albumin may help maintain oncotic pressure and reduce ascites. Albumin should be avoided in patients with traumatic brain injury, given concerns from the SAFE trial subgroup analysis showing increased mortality with albumin use in TBI patients.

Recommendation 46 — Starches

For adults with sepsis or septic shock, we recommend against using starches for acute resuscitation.

Strong recommendation, high certainty evidence

Change from 2021: Carryover.

Rationale: This statement was carried over; please see the 2021 SSC guidelines for rationale.¹ Hydroxyethyl starch (HES) solutions have been consistently associated with increased mortality and acute kidney injury requiring renal replacement therapy in patients with sepsis and septic shock. This strong recommendation against their use is supported by high certainty evidence from multiple large RCTs.

Recommendation 47 — Gelatin

For adults with sepsis or septic shock, we suggest against using gelatin for acute resuscitation.

Conditional recommendation, moderate certainty evidence

Change from 2021: Carryover.

Rationale: This statement was carried over; please see the 2021 SSC guidelines for rationale.¹ Gelatin-based colloids have not demonstrated benefit over crystalloids and carry potential risks including anaphylaxis, coagulopathy, and renal impairment. Available evidence does not support their use as resuscitation fluids in sepsis or septic shock.

3. Liberal vs. Conservative Fluid Approach

Recommendation 48 — Liberal vs. Restrictive Fluid Strategy

For adults with sepsis or septic shock, we suggest using either a liberal or a restrictive fluid strategy based on individual patient and health system factors.

Conditional recommendation, low certainty evidence

Change from 2021: Revisited.

Rationale: The optimal total volume of fluid resuscitation after the initial bolus remains uncertain. There is wide variability in protocols defining “liberal” and “restrictive” strategies across published studies, making direct comparison challenging.

The panel reviewed four RCTs involving 3,320 patients that compared restrictive vs. liberal fluid strategies in sepsis or septic shock. There was no difference in mortality between restrictive and liberal approaches (RR 1.00; 95% CI, 0.91–1.10, moderate certainty). No significant differences were observed in ICU or hospital length of stay, ventilator-free days, or renal replacement therapy.

The European Society of Intensive Care Medicine (ESICM) similarly made no recommendation favoring one approach over the other.

Remark: Given the absence of a clear mortality benefit for either strategy, clinicians should individualize fluid administration based on:

• Hemodynamic response to initial resuscitation
• Dynamic measures of fluid responsiveness (see Recommendation 49)
• Signs of fluid overload (pulmonary edema, peripheral edema, rising filling pressures)
• Organ perfusion markers (lactate trends, urine output, capillary refill)
• Health system resources and monitoring capabilities

4. Fluid Resuscitation Guided by Dynamic Measures

Recommendation 49 — Dynamic Measures of Fluid Responsiveness

For adults with sepsis or septic shock, we suggest using dynamic measures over physical examination or static measures alone to guide fluid resuscitation.

Conditional recommendation, low certainty evidence

Change from 2021: Revisited.

Rationale: Dynamic measures of fluid responsiveness assess the change in cardiac output or its surrogates in response to a defined hemodynamic challenge. These include:

• Passive leg raise (PLR) with measurement of stroke volume or cardiac output
• Fluid bolus challenge with measurement of stroke volume change
• Stroke volume variation (SVV) in mechanically ventilated patients
• Pulse pressure variation (PPV) in mechanically ventilated patients

Static measures such as central venous pressure (CVP) have poor predictive value for fluid responsiveness and should not be used as the sole guide.

Evidence from three meta-analyses encompassing 18 RCTs supports the use of dynamic measures. Dynamic measure-guided resuscitation likely reduces mortality (RR 0.91; 95% CI, 0.79–1.06, moderate certainty) and results in a large reduction in the need for renal replacement therapy (RR 0.75; 95% CI, 0.58–0.98, moderate certainty).

Point-of-care ultrasound (POCUS)-guided resuscitation, evaluated separately, probably reduces 28-day mortality (RR 0.88; 95% CI, 0.78–0.99), supporting its integration into bedside assessment.

Comparison of assessment methods:

5. Cardiac Output Monitoring

Recommendation 50 — Minimally Invasive or Noninvasive Cardiac Output Monitoring

There is insufficient evidence to make a recommendation regarding the routine use of minimally invasive or noninvasive cardiac output monitoring in adults with sepsis or septic shock.

No recommendation

Change from 2021: New.

Rationale: Minimally invasive cardiac output monitoring (e.g., arterial catheter-based pulse contour analysis, transpulmonary thermodilution) and noninvasive monitoring (e.g., bioreactance) are increasingly available in ICU settings. However, the panel found insufficient evidence from RCTs to determine whether routine use of these technologies improves patient outcomes in sepsis or septic shock.

Critical care ultrasound (echocardiography) was not evaluated in this recommendation, as it is addressed separately in the context of dynamic measures of fluid responsiveness and assessment of cardiac function.

“In our practice”: 74.6% of panelists have access to minimally invasive cardiac output monitors, and 31.3% have access to noninvasive cardiac output monitors.

6. Serial Lactate Measurement

Recommendation 51 — Serial Lactate to Guide Resuscitation

For adults with sepsis or septic shock, we suggest using serial lactate measurements to guide resuscitation.

Conditional recommendation, low certainty evidence

Change from 2021: Revisited.

Rationale: Serum lactate is an indirect marker of tissue hypoperfusion and anaerobic metabolism. Elevated lactate (> 2 mmol/L) is independently associated with increased mortality in sepsis. Serial measurements can track the trajectory of resuscitation and help identify patients who are responding (or failing to respond) to treatment.

Meta-analyses demonstrate that lactate-guided resuscitation therapy is associated with improved mortality compared with resuscitation without serial lactate monitoring. The key principle is to monitor for lactate decrement — specifically, a reduction of at least 10% every 2 hours — rather than targeting absolute normalization. Fluid administration should be individualized after the initial bolus, with lactate trends serving as one of multiple inputs guiding further resuscitation.

Clinical guidance for lactate-guided resuscitation:

• Measure initial lactate at sepsis recognition
• Repeat measurement every 2 hours during active resuscitation
• Target a reduction of at least 10% per 2 hours (lactate decrement approach)
• Do not pursue aggressive fluid loading solely to normalize lactate
• Integrate lactate trends with other perfusion markers (CRT, urine output, hemodynamics)
• Recognize non-perfusion causes of hyperlactatemia (epinephrine infusion, liver dysfunction, thiamine deficiency, beta-2 agonists)

Remark: In low resource settings where serial lactate monitoring is unavailable or impractical, capillary refill time and urinary output are acceptable alternatives for monitoring resuscitation adequacy.

7. Capillary Refill Time

Recommendation 52 — Capillary Refill Time as Adjunct Resuscitation Target

For adults with sepsis or septic shock, we suggest using capillary refill time to guide resuscitation as an adjunct to other measures of perfusion.

Conditional recommendation, low certainty evidence

Change from 2021: Revisited.

Rationale: Capillary refill time (CRT) is a noninvasive, bedside measure of peripheral perfusion assessed by applying firm pressure to the distal phalanx of the index finger for 10 seconds and measuring the time for color to return. A CRT of 3 seconds or less is considered normal.

Two RCTs involving 233 patients evaluated resuscitation strategies targeting CRT normalization (≤ 3 seconds). The combined evidence showed a reduction in 28-day mortality (RR 0.82; 95% CI, 0.65–1.04), corresponding to an absolute mortality reduction of approximately 74 fewer deaths per 1,000 patients.

The ANDROMEDA-SHOCK-2 RCT (1,467 patients), published after guideline finalization, provided further support for CRT-guided resuscitation. In this multicenter trial, a CRT-guided resuscitation protocol was associated with better outcomes compared with standard care (win ratio 1.16; 95% CI, 1.02–1.33, p = 0.04). This trial strengthens the rationale for incorporating CRT into bedside resuscitation assessment.

CRT assessment technique:

1. Apply firm pressure to the ventral surface of the distal phalanx of the index finger
2. Apply pressure for 10 seconds using a glass slide or fingertip
3. Release and measure time for full color return
4. Normal: ≤ 3 seconds
5. Abnormal: > 3 seconds (suggests impaired peripheral perfusion)
6. Reassess every 30 minutes during active resuscitation

Remark: CRT is free, immediately available, requires no equipment, and is particularly valuable in low resource settings. It should be used as an adjunct to other perfusion markers, not as a sole target. Limitations include operator variability, ambient temperature, skin pigmentation, and peripheral vascular disease.

8. IV Vasopressors

Recommendation 53 — Norepinephrine as First-Line Vasopressor

For adults with septic shock, we recommend norepinephrine as the first-line vasopressor agent over dopamine, epinephrine, or selepressin.

Strong recommendation

• Over dopamine: high certainty evidence
• Over epinephrine: low certainty evidence
• Over selepressin: low certainty evidence

Change from 2021: Carryover.

Rationale: Norepinephrine is a potent alpha-1 adrenergic agonist with modest beta-1 activity, producing vasoconstriction with modest augmentation of cardiac output. Evidence consistently demonstrates that norepinephrine is superior to dopamine (lower mortality, fewer arrhythmias) and at least equivalent to epinephrine and selepressin, with a more favorable side-effect profile.

Recommendation 54 — Terlipressin

For adults with septic shock, we suggest against using terlipressin.

Conditional recommendation, low certainty evidence

Change from 2021: Carryover.

Rationale: This statement was carried over; please see the 2021 SSC guidelines for rationale.¹ Terlipressin, a long-acting vasopressin analogue, has been associated with potential harms including digital ischemia and splanchnic vasoconstriction, without demonstrated mortality benefit over norepinephrine.

Recommendation 55 — Norepinephrine as First-Line Over Vasopressin or Angiotensin II

For adults with septic shock, we suggest norepinephrine as the first-line vasopressor agent over vasopressin or angiotensin II.

Conditional recommendation

• Over vasopressin: low certainty evidence
• Over angiotensin II: very low certainty evidence

Change from 2021: Revisited (downgraded from strong recommendation in 2021 to conditional).

Rationale: The 2021 SSC guidelines made a strong recommendation for norepinephrine over vasopressin. In 2026, this recommendation was downgraded to conditional based on updated evidence and panel deliberation.

Two RCTs involving 658 patients, including the landmark VASST trial, compared norepinephrine with vasopressin as a first-line agent. There was no difference in mortality (RR 1.07; 95% CI, 0.90–1.28). Vasopressin was probably associated with less atrial fibrillation (RR 0.66; 95% CI, 0.42–1.05) but possibly more digital ischemia (RR 2.87; 95% CI, 0.84–9.82).

No RCTs have compared angiotensin II as a first-line vasopressor agent in septic shock. Angiotensin II (a synthetic form of the endogenous hormone) acts primarily through AT1 receptors to produce vasoconstriction. While the ATHOS-3 trial demonstrated that angiotensin II could augment blood pressure in vasodilatory shock, it was studied as an add-on agent, not as first-line therapy.

Remark: Vasopressin and angiotensin II tend to be more expensive and less widely available than norepinephrine, particularly in low- and middle-income countries (LMICs). These practical considerations, combined with the broader evidence base and clinical familiarity with norepinephrine, support its continued role as the preferred first-line agent.

Recommendation 56 — Adding Vasopressin on Escalating Norepinephrine Doses

For adults with septic shock on norepinephrine, we suggest adding vasopressin on escalating doses of norepinephrine rather than further increasing norepinephrine dose alone.

Conditional recommendation, moderate certainty evidence

Change from 2021: Revisited.

Rationale: In septic shock, vasopressin deficiency develops as endogenous stores are depleted, contributing to catecholamine-refractory hypotension. Exogenous vasopressin replaces this deficiency and augments vasoconstriction through V1 receptors, acting via a mechanism independent of adrenergic pathways.

A meta-analysis of nine RCTs involving 1,439 patients, including the VASST trial, demonstrated that the addition of vasopressin to norepinephrine probably reduces mortality compared with norepinephrine alone (RR 0.89; 95% CI, 0.79–1.01, moderate certainty).

“In our practice”: 85.1% of panelists add vasopressin as a second-line agent, initiating it at a median norepinephrine dose of 0.3 micrograms/kg/min (IQR, 0.2–0.5 micrograms/kg/min). Vasopressin is typically administered at a fixed dose of 0.03 units/min (not titrated).

Recommendation 57 — Adding Epinephrine as Third-Line Vasopressor

For adults with septic shock with inadequate MAP despite norepinephrine and vasopressin, we suggest adding epinephrine.

Conditional recommendation, very low certainty evidence

Change from 2021: Revisited.

Rationale: Epinephrine is a potent alpha-1 and beta-1 agonist that increases both vascular tone and cardiac output. In patients who remain hypotensive despite norepinephrine and vasopressin, epinephrine represents a third-line option.

A network meta-analysis of 31 RCTs involving 5,928 patients found an uncertain mortality effect of epinephrine added to other vasopressors (OR 0.65; 95% CI, 0.19–2.18, very low certainty). The wide confidence interval reflects limited direct evidence for epinephrine specifically as a third-line agent.

“In our practice”: 55.2% of panelists add epinephrine as a third-line agent, initiating it at a median norepinephrine dose of 0.8 micrograms/kg/min (IQR, 0.5–1.0 micrograms/kg/min).

Remark: Where vasopressin is unavailable, epinephrine can be added directly to norepinephrine as a second-line agent. Epinephrine increases heart rate and myocardial oxygen demand and may cause splanchnic vasoconstriction and hyperlactatemia, which can confound lactate-guided resuscitation.

Recommendation 58 — Septic Shock with Concomitant Cardiac Dysfunction

For adults with septic shock and concomitant cardiac dysfunction, we suggest using either norepinephrine or epinephrine as the first-line vasopressor agent.

Conditional recommendation, very low certainty evidence

Change from 2021: New.

Rationale: Sepsis-related cardiomyopathy occurs in a substantial proportion of patients with septic shock and is characterized by biventricular systolic dysfunction, diastolic dysfunction, or both. In this setting, the choice between norepinephrine and epinephrine as first-line agent may be guided by the patient’s cardiac rhythm.

The CAT Study (280 patients) and a network meta-analysis provide the evidence base for this recommendation, though certainty is very low.

Guidance for first-line agent selection based on cardiac rhythm:

9. Methylene Blue

Recommendation 59 — Methylene Blue in Refractory Septic Shock

For adults with refractory septic shock and escalating vasopressor requirements, there is insufficient evidence to make a recommendation regarding intravenous methylene blue.

No recommendation

Change from 2021: New.

Rationale: Methylene blue is a phenothiazine derivative that inhibits inducible nitric oxide synthase (iNOS) and soluble guanylate cyclase (sGC), reducing pathologic vasodilation mediated by the nitric oxide–cyclic GMP pathway. In theory, it addresses a mechanism of vasoplegia that is not targeted by catecholamines or vasopressin.

An updated review identified six RCTs evaluating methylene blue in septic shock. The evidence for mortality reduction was of very low certainty (RR 0.79; 95% CI, 0.60–1.03). However, methylene blue likely results in a reduction in vasopressor duration (MD -1.0 day; 95% CI, -1.8 to -0.20, moderate certainty), which may be clinically meaningful.

“In our practice”: Use remains uncommon — 69% of panelists report “never” or “almost never” using methylene blue, 23% use it “sometimes,” 6% “usually,” and 1.5% “almost always.”

Key considerations:

• Contraindicated in patients taking serotonergic medications (risk of serotonin syndrome)
• Contraindicated in G6PD deficiency (risk of hemolytic anemia)
• Interferes with pulse oximetry readings (falsely low SpO2)
• Typical dosing: 1–2 mg/kg IV bolus, may repeat or follow with infusion
• May cause blue-green discoloration of urine and skin

10. Inotropes

Recommendation 60 — Inotropes for Persistent Hypoperfusion with Cardiac Dysfunction

For adults with septic shock, persistent hypoperfusion, and evidence of cardiac dysfunction despite adequate fluid resuscitation and vasopressor therapy, we suggest using inotropes over no inotropes.

Conditional recommendation, very low certainty evidence

Change from 2021: Revisited.

Rationale: Sepsis-related cardiomyopathy with reduced cardiac output can contribute to persistent tissue hypoperfusion despite adequate volume resuscitation and vasopressor support. In this setting, the addition of an inotropic agent aims to augment cardiac output and improve oxygen delivery.

A network meta-analysis of 33 trials involving 3,470 patients found an uncertain mortality effect of dobutamine (OR 0.69; 95% CI, 0.32–1.47, very low certainty). Despite the absence of definitive mortality benefit, the pathophysiologic rationale and clinical experience support inotrope use in patients with documented cardiac dysfunction and persistent hypoperfusion.

Remark: Inotropes should be added to (not used as a replacement for) vasopressors. The decision to initiate inotropic therapy should be based on objective evidence of cardiac dysfunction (echocardiography, cardiac output monitoring) and ongoing hypoperfusion (rising lactate, poor CRT, low ScvO2) despite hemodynamic optimization.

“In our practice”: 94% of panelists use inotropes in this clinical scenario. Agent preferences: dobutamine 71.4%, milrinone 12.7%, epinephrine 14.3%.

Recommendation 61 — Choice of Inotropic Strategy

For adults with septic shock, persistent hypoperfusion, and cardiac dysfunction, we suggest adding dobutamine to norepinephrine or using epinephrine alone.

Conditional recommendation, very low certainty evidence

Change from 2021: Revisited.

Rationale: Two inotropic strategies are commonly used in septic shock with cardiac dysfunction:

1. Norepinephrine + dobutamine — separates vasopressor and inotropic effects, allowing independent titration
2. Epinephrine alone — provides both vasopressor and inotropic effects in a single agent, simplifying the infusion regimen

One RCT of 330 patients compared norepinephrine plus dobutamine with epinephrine alone and found no difference in 90-day mortality (RR 0.96; 95% CI, 0.78–1.19). No significant differences were observed in other patient-important outcomes.

Remark: There is insufficient evidence to guide the choice between dobutamine and milrinone. Milrinone, a phosphodiesterase-3 inhibitor, provides inotropic and vasodilatory effects but may worsen hypotension and has a longer half-life, making titration more challenging. Clinicians should select the inotropic agent based on institutional availability, familiarity, and patient-specific factors (heart rate, blood pressure, rhythm).

Recommendation 62 — Levosimendan

For adults with sepsis or septic shock, we suggest against using levosimendan.

Conditional recommendation, low certainty evidence

Change from 2021: Carryover.

Rationale: This statement was carried over; please see the 2021 SSC guidelines for rationale.¹ Levosimendan, a calcium-sensitizer inodilator, has not demonstrated mortality benefit in RCTs of septic shock and is associated with hypotension and tachyarrhythmias.

11. Midodrine

Recommendation 63 — Oral Midodrine for Patients on Vasopressors

For adults with sepsis or septic shock receiving vasopressors, there is insufficient evidence to make a recommendation regarding oral midodrine.

No recommendation

Change from 2021: New.

Rationale: Midodrine is an oral alpha-1 adrenergic agonist that has been used as an adjunctive agent to facilitate vasopressor weaning and ICU discharge. Its use reflects clinical interest in transitioning patients from IV vasopressors to oral vasoactive support during the recovery phase.

Seven small RCTs involving 448 patients evaluated midodrine in this context. The results showed uncertain effects on mortality, renal replacement therapy, acute kidney injury, and acute hepatic failure, with insufficient evidence to determine benefit or harm.

“In our practice”: 32.8% of panelists use midodrine. Among those who use it, 86.4% initiate midodrine after the acute phase of septic shock (i.e., during vasopressor weaning rather than during initial resuscitation).

12. Beta-Blockers

Recommendation 64 — Beta-Blockers as Treatment for Septic Shock

For adults with septic shock, we suggest against using beta-blockers as treatment.

Conditional recommendation, very low certainty evidence

Change from 2021: New.

Rationale: Tachycardia in septic shock is common and may be maladaptive, increasing myocardial oxygen demand, reducing diastolic filling time, and contributing to tachycardia-induced cardiomyopathy. Short-acting IV beta-blockers (esmolol and landiolol) have been investigated as therapeutic interventions to control heart rate in this setting.

The most comprehensive meta-analysis included 12 RCTs involving 1,170 patients. Key findings:

Despite the point estimate suggesting a potential mortality reduction, the very low certainty of the evidence — driven by small trials, high risk of bias, and significant heterogeneity — precluded the panel from recommending beta-blocker use. The probable increase in vasopressor duration is a significant concern, as it suggests that the hemodynamic effects of beta-blockade (reduced cardiac output, reduced heart rate) may necessitate higher vasopressor doses.

Remark: This recommendation applies to the use of beta-blockers as a treatment strategy for septic shock per se. It does not apply to patients who are receiving beta-blockers for other established indications (e.g., rate control of atrial fibrillation, acute coronary syndrome, or continuation of chronic beta-blocker therapy where abrupt discontinuation may be harmful).

Figure 3: Hemodynamic Management Algorithm

HEMODYNAMIC MANAGEMENT IN SEPSIS AND SEPTIC SHOCK — QUICK ALGORITHM
(Adapted from SSC 2026 Figure 3)

PATIENT WITH SEPSIS AND HYPOTENSION / ELEVATED LACTATE
│
├── MONITORING (within 1 hour)
│   ├── Hourly: BP, HR, RR, level of consciousness
│   ├── Measure initial blood lactate
│   ├── Assess capillary refill time (CRT)
│   └── Consider invasive monitoring if intermediate-high dose vasopressors,
│       escalating doses, multiple vasopressors, or inconsistent NIBP
│
├── INITIAL FLUID RESUSCITATION (within 3 hours)
│   ├── ≥ 30 mL/kg IV crystalloid
│   ├── Use balanced crystalloids (preferred over 0.9% saline)
│   │   └── Exception: use 0.9% saline if concomitant TBI
│   ├── Crystalloids alone (albumin not routinely added)
│   └── AVOID: starches, gelatin
│
├── VASOPRESSORS
│   ├── 1st LINE: Norepinephrine
│   │   ├── Start peripherally if no central access
│   │   └── Target MAP ≥ 65 mmHg (or 60-65 mmHg if age ≥ 65)
│   │
│   └── May start concurrently with fluids if unstable shock
│
▼
REASSESS: Does hypotension / lactate elevation persist?
│
├── YES ──────────────────────────────────────────────────────────┐
│                                                                 │
│   ┌─ ASSESS FLUID RESPONSIVENESS ────────────────────────┐      │
│   │  Use dynamic measures:                               │      │
│   │  • Passive leg raise + stroke volume / CO change     │      │
│   │  • SVV / PPV (if mechanically ventilated)            │      │
│   │  • POCUS (IVC, VTI)                                  │      │
│   │  • Fluid bolus challenge with SV monitoring          │      │
│   └──────────────────────────────────────────────────────┘      │
│                                                                 │
│   ┌─ FLUID RESPONSIVE? ─────────────────────────────────┐      │
│   │  YES → Additional fluid boluses guided by response   │      │
│   │  NO  → Stop further fluid loading                    │      │
│   └──────────────────────────────────────────────────────┘      │
│                                                                 │
│   ┌─ VASOPRESSOR ESCALATION ─────────────────────────────┐      │
│   │  1. Initiate NE if not already started               │      │
│   │  2. Add vasopressin if NE dose increasing            │      │
│   │     (median initiation: NE 0.3 µg/kg/min)           │      │
│   │  3. Add epinephrine as third-line if MAP still       │      │
│   │     inadequate on NE + vasopressin                   │      │
│   │     (median initiation: NE 0.8 µg/kg/min)           │      │
│   └──────────────────────────────────────────────────────┘      │
│                                                                 │
│   ┌─ CORTICOSTEROIDS ────────────────────────────────────┐      │
│   │  Add hydrocortisone ± fludrocortisone if NE          │      │
│   │  requirement persists (see Part 4)                   │      │
│   └──────────────────────────────────────────────────────┘      │
│                                                                 │
│   ┌─ CARDIAC DYSFUNCTION? ───────────────────────────────┐      │
│   │  Assess with echocardiography / cardiac output       │      │
│   │  monitoring                                          │      │
│   │                                                      │      │
│   │  IF cardiac dysfunction + persistent hypoperfusion:  │      │
│   │  • Add dobutamine to NE                              │      │
│   │    — OR —                                            │      │
│   │  • Use epinephrine alone (provides vasopressor +     │      │
│   │    inotropic effects)                                │      │
│   │                                                      │      │
│   │  HEART RATE GUIDANCE:                                │      │
│   │  • Tachyarrhythmia → prefer NE                       │      │
│   │  • Bradyarrhythmia → prefer epinephrine              │      │
│   └──────────────────────────────────────────────────────┘      │
│                                                                 │
│   ┌─ MONITOR RESUSCITATION TARGETS ──────────────────────┐      │
│   │  • Serial lactate q2h (target ≥ 10% reduction/2h)   │      │
│   │  • Capillary refill time (target ≤ 3 sec)           │      │
│   │  • Urine output                                      │      │
│   │  • MAP at target                                     │      │
│   │  • Level of consciousness                            │      │
│   └──────────────────────────────────────────────────────┘      │
│                                                                 │
└── NO → Continue monitoring, serial reassessment ────────────────┘

Quick Reference: Hemodynamic Management Summary

HEMODYNAMIC MANAGEMENT — AT A GLANCE

A. BLOOD PRESSURE MONITORING
   ✓  Either invasive or noninvasive BP monitoring              [Conditional]
      Remark: invasive advised for escalating/high-dose vasopressors,
      multiple agents, frequent sampling, or unreliable NIBP

B. FLUID TYPE
   ✓✓ Crystalloids as first-line resuscitation fluid             [Strong]
   ✓  Balanced crystalloids over 0.9% saline                     [Conditional]
      Remark: use 0.9% saline if concomitant TBI
   ✓  Crystalloids alone over crystalloids + albumin              [Conditional]
      Remark: albumin may be appropriate after large volumes or in cirrhosis
   ✗✗ Against starches                                            [Strong against]
   ✗  Against gelatin                                             [Conditional against]

C. FLUID STRATEGY
   ✓  Either liberal or restrictive strategy, individualized      [Conditional]

D. FLUID RESPONSIVENESS
   ✓  Dynamic measures over physical exam / static measures       [Conditional]
      (PLR, SVV, PPV, POCUS, fluid bolus challenge)

E. CARDIAC OUTPUT MONITORING
   —  Minimally invasive / noninvasive CO monitoring:             [No rec]
      insufficient evidence

F. RESUSCITATION TARGETS
   ✓  Serial lactate (target ≥ 10% reduction per 2 hours)        [Conditional]
   ✓  Capillary refill time as adjunct (target ≤ 3 seconds)      [Conditional]

G. VASOPRESSORS
   ✓✓ Norepinephrine first-line over dopamine/epinephrine/        [Strong]
      selepressin
   ✗  Against terlipressin                                        [Conditional against]
   ✓  NE first-line over vasopressin or angiotensin II            [Conditional] ⬇ DOWNGRADED
   ✓  Add vasopressin on escalating NE doses                      [Conditional]
      (median initiation at NE 0.3 µg/kg/min)
   ✓  Add epinephrine if inadequate MAP on NE + vasopressin       [Conditional]
      (median initiation at NE 0.8 µg/kg/min)
   ✓  NE or epinephrine first-line if cardiac dysfunction         [Conditional] NEW
      (tachyarrhythmia → NE; bradyarrhythmia → epinephrine)

H. METHYLENE BLUE
   —  Insufficient evidence for IV methylene blue in              [No rec] NEW
      refractory septic shock
      (may reduce vasopressor duration; very low certainty
      mortality data)

I. INOTROPES
   ✓  Inotropes for persistent hypoperfusion + cardiac            [Conditional]
      dysfunction (add to, not replace, vasopressors)
   ✓  Dobutamine + NE or epinephrine alone                        [Conditional]
   ✗  Against levosimendan                                        [Conditional against]

J. MIDODRINE
   —  Oral midodrine for patients on vasopressors:                [No rec] NEW
      insufficient evidence

K. BETA-BLOCKERS
   ✗  Against beta-blockers as treatment for septic shock         [Conditional against] NEW
      (may increase vasopressor duration despite possible
      mortality signal)

KEY: ✓✓ = Strong recommendation ("we recommend")
     ✓  = Conditional recommendation ("we suggest")
     ✗  = Conditional against ("we suggest against")
     ✗✗ = Strong against ("we recommend against")
     GPS = Good practice statement
     —  = No recommendation / insufficient evidence
     ⬇  = Downgraded from 2021
     NEW = New recommendation in 2026

References