ICU Map

Initial Hemodynamic Resuscitation & Shock Bundling

From recognizing hypoperfusion and initial crystalloid bolus to dynamic fluid responsiveness assessment and vasopressor targets.

RecognizeAssessDecideDifferentialInterveneReassess
Hypotension / Undifferentiated Shock / Lactate > 2.0
Assessment StepRecognize shock: MAP < 65 mmHg, Lactate > 2.0, or tissue hypoperfusionExplore Topic
Assess capillary refill time (>3s), mottling score, altered mentation, and urine output (<0.5 mL/kg/h).
Clinical ActionSecure vascular access & draw baseline lactate / blood gas
Place 2 large-bore peripheral IVs (16/18G) or central venous line; send repeat lactate at 2–4 hours to calculate clearance.
Clinical ActionFor sepsis-induced hypoperfusion/shock, give initial balanced crystalloid with frequent reassessment (SSC 2026 suggests at least 30 mL/kg in the first 3 h, individualized)
Use Plasmalyte or Lactated Ringer's to avoid hyperchloremic metabolic acidosis associated with 0.9% Normal Saline.
Clinical ActionStart early peripheral/central Norepinephrine if MAP < 50–55 mmHg
Do not wait for complete fluid infusion if profound hypotension threatens coronary or cerebral perfusion.
Decision PointPerform dynamic fluid responsiveness assessmentExplore Topic
Use Passive Leg Raise (PLR) with continuous cardiac output/VTI measurement, Pulse Pressure Variation (PPV in ventilated sinus rhythm), or stroke volume change.
Differential Branches (2)
1Branch
Clinical ActionFluid Responsive (Stroke Volume rise >= 10–15%)
Administer cautious additional aliquots (250–500 mL) and re-test responsiveness after each bolus. Stop fluids when non-responsive.
2Branch
Reassessment / LoopNon-Responsive: Cease fluid boluses & optimize vasoactive supportExplore Topic
Prevent fluid overload, which increases pulmonary edema, AKI, and ICU mortality. Titrate vasopressors to MAP >= 65 mmHg.

An educational representation of clinical reasoning, not a diagnostic algorithm or personalized medical advice — always apply clinical judgment and institutional protocols.

Caution

Escalate — Red Flags & Critical Warnings

  • Continuing indiscriminate fluid administration in non-responsive shock causes tissue edema, worsening pulmonary gas exchange, and increased ICU mortality.
  • Escalating vasopressor requirements should trigger prompt multimodal reassessment (including bedside echocardiography where appropriate), consideration of vasopressin in septic vasoplegia, and corticosteroids for persistent vasopressor-dependent septic shock rather than reliance on one norepinephrine cutoff.

Related Bedside Clinical Problems (26)

Bedside Presentations
Sudden Hypoxemia

Bedside triage of acute desaturation: signal verification, immediate danger screening (DOPE / tension pneumothorax), oxygen escalation ladder, and mechanism-based differential.

View Bedside Problem →
Acute Hypotension & Undifferentiated Shock

Rapid bedside hemodynamic categorization: confirming MAP < 65 mmHg, assessing peripheral perfusion, POCUS cardiac/IVC profiling, and differentiating hypovolemic, distributive, cardiogenic, and obstructive etiologies.

View Bedside Problem →
Refractory Shock Despite High-Dose Vasopressors

Advanced multimodal hemodynamic rescue: second-line vasopressors (vasopressin, angiotensin II), inotropic augmentation, stress-dose steroids, metabolic correction, and mechanical circulatory support evaluation.

View Bedside Problem →

Linked Deep-Dive Topics (11)

Reference Knowledge
Shock: Foundational Critical Care Frameworkcardiovascular

Cellular dysoxia, DO2/VO2 physiology, the 4 shock phenotypes, dynamic fluid responsiveness (PLR/PPV) vs fluid tolerance (VExUS), and vasoactive pharmacology.

Explore Topic →
Septic Shockcardiovascular

The subset of sepsis with profound circulatory and cellular/metabolic abnormality — clinically identified by a vasopressor requirement to maintain MAP ≥ 65 mmHg plus lactate > 2 mmol/L despite adequate fluid resuscitation.

Explore Topic →
Cardiogenic Shockcardiovascular

Primary pump failure, SCAI staging (A–E), PAC hemodynamics (CPO, PAPi), inotrope selection, emergent revascularization, and mechanical circulatory support.

Explore Topic →
Acute Right Ventricular Failurecardiovascular

RV anatomy and ischemia spiral, ventricular interdependence (D-sign), echocardiographic metrics (TAPSE, S', PAPi, VExUS), and the 4-pillar resuscitation strategy.

Explore Topic →
Acute Coronary Syndromecardiovascular

Plaque rupture, coronary thrombosis, STEMI vs NSTEMI risk stratification, emergent reperfusion, DAPT/anticoagulation, and mechanical/electrical ICU complications.

Explore Topic →
Acute Heart Failure & Cardiogenic Congestioncardiovascular

Hemodynamic phenotypes (SCAPE vs ADHF vs Cardiogenic Shock), non-invasive positive pressure ventilation, high-dose vasodilator algorithms, loop diuretics, and sequential nephron blockade.

Explore Topic →
Burns & Major Burn Critical Carespecial-critical-care

Inhalation injury management, endpoint-driven fluid resuscitation, avoidance of fluid creep, bedside escharotomy, and hypermetabolic catabolism support.

Explore Topic →
Sepsisinfectious-disease

Life-threatening organ dysfunction caused by a dysregulated host response to infection — recognized by an acute rise in SOFA score, not by infection plus fever alone.

Explore Topic →
Arrhythmias in Critical Illnesscardiovascular

Algorithmic tachy- and bradyarrhythmia management, new-onset ICU atrial fibrillation, wide-complex tachycardia differentiation, and refractory Torsades overdrive pacing protocols.

Explore Topic →
Acute Mesenteric Ischemia (AMI)gi-hepatic

Rapid biphasic CTA diagnosis, mechanism-specific revascularization (embolism vs thrombosis vs venous thrombosis vs NOMI), individualized therapeutic anticoagulation, and selective second-look laparotomy.

Explore Topic →
Acute Aortic Syndromescardiovascular

Emergency classification, anti-impulse medical stabilization, and surgical vs endovascular management of aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer.

Explore Topic →

Evidence status

Review metadata not yet recorded.

Status, review dates and guideline versions appear here once editorial metadata is authored for this content.