Disclaimer
This is an Experimental Protocol, Please Follow Advice of your Doctor. This is not medical advice.
Introduction & Goal
The Clinical Challenge
The optimal strategy for hemodynamic resuscitation in early septic shock remains uncertain.
The Goal
This protocol uses sequential, multilayered assessments of physiological signals to tailor fluids, vasopressors, and inotropes, specifically targeting the normalization of Capillary Refill Time (CRT). CRT assessment can identify tissue hypoperfusion, and its evolution reflects the progress of resuscitation.
Tier 1 Interventions
Patients with an abnormal CRT receive a progressive two-tier intervention, beginning with the evaluation of pulse pressure.
Step 1 Evaluate Pulse Pressure & Diastolic Blood Pressure
If CRT remains abnormal, give 2nd fluid bolus if still responsive.
Tier 2 Interventions
Echocardiography
Perform basic echocardiography to rule out cardiac dysfunction. If right or left ventricular dysfunction is present, provide general treatment recommendations and record interventions.
Fluid Boluses
If cardiac dysfunction is ruled out or interventions fail to normalize CRT, reassess fluid responsiveness. Administer further fluid boluses to responsive patients until CRT normalizes, safety limits are met, or the patient becomes unresponsive.
MAP Test
If CRT remains abnormal, perform a MAP test only in patients with chronic hypertension by transiently increasing norepinephrine to attain a MAP of 80 to 85 mm Hg for 1 hour. If CRT goal is met, maintain this MAP.
Dobutamine Test
If MAP test fails, decrease norepinephrine to previous dose and perform a dobutamine test at fixed low dose (5 µg/kg/min) for 1 hour. Maintain dobutamine only if CRT normalizes.
Measuring Fluid Responsiveness
The protocol encourages dynamic parameters to predict stroke volume increase.
Pulse Pressure Variation (PPV)
Often the first choice for patients who are deeply sedated, on controlled mechanical ventilation, and in sinus rhythm.
Passive Leg Raising (PLR) Test
Primary method for patients with spontaneous breathing, arrhythmias, or low lung compliance. Measure response using Echocardiography (VTI of LVOT) rather than just blood pressure changes.
End-Expiratory Occlusion Test (EEOT)
Assessing changes in cardiac output or pulse pressure after a 15-second pause at the end of expiration.
Tidal Volume Challenge
Transiently increasing tidal volume from 6 mL/kg to 8 mL/kg to see if it "unmasks" pulse pressure variation in patients ventilated with low tidal volumes.
Vena Cava Variability
Assessing respiratory variations in the Inferior Vena Cava (IVC) or Superior Vena Cava (SVC) using ultrasound.
CRT-PHR Algorithm Flowchart
Standardized CRT Assessment
Apply firm pressure to the ventral surface of the distal phalanx of a finger using a glass microscope slide.
Increase the pressure until the skin is blank, maintain it for 10 seconds, and then release it.
Measure the time required to return to the normal skin color using a chronometer.