Experts preview ongoing work on guidelines for hemodynamic monitoring in septic shock

Experts addressed topics related to upcoming guidelines for hemodynamic monitoring in adult patients with sepsis and septic shock during a two-part session on Tuesday, October 21, at CHEST 2025 in Chicago.

During Hemodynamic Monitoring Guideline Updates for Adult Patients With Sepsis and Septic Shock: Part 1, presenters focused on evidence-based use of four specific hemodynamic monitoring themes: fluid responsiveness, invasive vs noninvasive blood pressure monitoring, target mean arterial pressure (MAP) for resuscitation, and invasive central venous pressure (CVP)-guided therapy. Both parts of the session will be available for on-demand viewing on the CHEST MedCast platform later this year.

Fluid responsiveness

Namita Jayaprakash, MB, BCh, BAO, reviewed studies on techniques to assess fluid responsiveness, a crucial part in identifying an optimal fluid resuscitation zone for patients in septic shock.

Intensivists mostly rely on variations of two different techniques to assess fluid responsiveness: the passive leg raise and ultrasound-based inferior vena cava (IVC) assessments, said Dr. Jayaprakash, Associate Medical Director for Quality and Patient Safety in the Department of Emergency Medicine and the Sepsis Program Physician Lead at Henry Ford Health.

“Determining fluid responsiveness in an ICU setting at the bedside can be challenging but feasible,” she said. “Passive leg raise and IVC assessments are often utilized in our practice, and their role is really in supporting the clinicians’ decision-making and increasing their confidence, but there is not as much of a clear impact on patient-centered outcomes mortality.”

Invasive vs noninvasive blood pressure monitoring

Deepa Bangalore Gotur, MD, EdD, FCCP, examined studies comparing invasive and noninvasive blood pressure monitoring and recommended early invasive arterial blood pressure for septic shock monitoring.

Dr. Gotur, Associate Professor of Clinical Medicine at Weill Cornell Medicine, noted the relative ease and convenience of various noninvasive blood pressure monitoring methods. By contrast, invasive blood pressure monitoring requires a systematic five-step process with additional considerations for placing and managing the catheter.

A series of studies favor invasive monitoring, Dr. Gotur said. For example, one study found noninvasive blood pressure monitoring led to a large percentage of readings outside the range of acceptable agreement. Another large-scale study of critically ill patients with septic shock found that noninvasive blood pressure monitoring techniques clinically and significantly underestimated MAP readings. Additional studies have shown that the timeliness of invasive monitoring also plays a role.

Some questions remain about the role of norepinephrine in narrowing differences between the two methods and about how site selection in invasive monitoring might affect MAP score accuracy, Dr. Gotur said. But these possibilities must be considered against information such as a 2022 study demonstrating that invasive monitoring is significantly more likely to detect occult hypotension compared with noninvasive methods. ​

“This is critical for timely and effective clinical management, especially in [patients who are septic],” Dr. Gotur said.

Target MAP for resuscitation

Accurately measuring blood pressure allows intensivists to target an ideal MAP score—but what should that be, and why do we use MAP scores? Siddharth Dugar, MD, FCCP, Assistant Professor of Medicine at Lerner College of Medicine, noted that MAP is a measure of macrocirculation whereas septic shock is at the level of microcirculation.

“Shock is at the cellular level, but what we do is improve the microcirculation by giving patients fluids and vasopressors. We target the blood pressure in the hope that the macrocirculation is in coherence with the microcirculation, so that as we improve the microcirculation, we improve the microcirculation,” he said.

Recent studies have examined the MAP target number of 65 for patients in septic shock and found that some subgroups have improved outcomes with slightly lower numbers in the 60 to 65 range. But no groups have presented better outcomes with higher target numbers, Dr. Dugar said.

Looking ahead, Dr. Dugar said that a starting goal of 65 mm Hg is “generally appropriate” for sepsis resuscitation, but that “once stabilized, the MAP target should be individualized, according to underlying comorbidities, microcirculatory status, and organ dysfunction.”

Invasive CVP-guided therapy

H. Bryant Nguyen, MD, MS, MBA, made the case for retaining CVP as a tool in assessing fluids in the treatment of sepsis. Dr. Nguyen, Professor of Medicine and Emergency and the Head of Pulmonary, Critical Care, and Sleep Medicine at Loma Linda University, noted known CVP limitations, such as not correlating to blood volume and being prone to falsely elevating readings in certain conditions.

“But is CVP associated with a good outcome?” Dr. Nguyen asked. “Surprisingly, maybe. Probably.” He pointed to a 2020 large analysis of the MIMIC-III database that showed the CVP group had more vasopressor-free days, more ventilator-free days, lower mortality, and lower one-year mortality. Other studies have shown no significant differences in outcome comparing IVC vs CVP and extravascular lung water/intrathoracic blood volume vs CVP.

Dr. Nguyen said CVP is particularly useful when a central venous catheter is already necessary for vasopressor administration. “I still use CVP,” Dr. Nguyen said in assessing its role as a tool in fluid assessment in response to septic shock. “If you don’t have a central line [in the patient], then pick your favorite, whether it’s IVC, PPV, etc. None of them have a difference in outcome, just know the limitations.”