Resuscitation and de-resuscitation endpoints in septic shock: Assessment of physiological determinants, fluid dynamics, and clinical outcomes

Septic shock management requires a delicate balance between adequate resuscitation and preventing fluid overload, with distinct phases requiring different therapeutic approaches and monitoring strategies. This thesis explores the critical endpoints for both the resuscitation and de-resuscitation phases of septic shock management.
In the initial resuscitation phase, early recognition and intervention are paramount. While traditional endpoints such as mean arterial pressure and lactate clearance have guided therapy, emerging evidence suggests that capillary refill time (CRT) serves as a superior resuscitation marker.

Pursuing CRT-guided resuscitation has demonstrated improved outcomes, including reduced mortality rates and faster resolution of organ dysfunction. During this phase, septic shock-induced hyperpermeability leads to significant fluid leakage, a phenomenon that clinical examination alone fails to assess adequately. More objective methods to evaluate fluid transudation are discussed in this thesis. The subsequent de-resuscitation phase, which focuses on removing excess fluid, becomes crucial once the acute shock period stabilizes. A key consideration during this period is the successful weaning from mechanical ventilation, which depends on achieving optimal balance between cardiac loading conditions and function. The implementation of physiology-based endpoints, remarkably fluid responsiveness, enables a more rational approach to fluid management and has been associated with improved patient outcomes.

The thesis emphasizes that monitoring strategies must be tailored to individual patient needs, with careful consideration of both immediate and long-term consequences, especially regarding cardiopulmonary interactions and organ dysfunction. This work presents a physiology-driven framework for fluid therapy in septic shock.