Version July 2025
| Assessments | Interventions as indicated |
| Determine risk | |
| Moderate risk - Normal BP; elevated SI >0.7 | |
| High risk - Low BP; elevated SI >0.7 | |
| Assess volume status | |
| Passive leg raise | |
| Arterial waveform analysis | |
| POCUS volume assessment | Replete volume and reduce vasoplegia as needed |
| SV variation high and pulse pressure low: Likely high SVR and volume depletion (eg, hemorrhagic shock) | If volume depleted, give appropriate fluid (blood or boluses of isotonic IVF). |
| SV variation low and pulse pressure high: Likely vasoplegia (eg, gram negative sepsis) | If vasoplegia present, start norepinephrine infusion. |
| POCUS cardiac function assessment | Augment left ventricle as needed |
| LV poor contractility (low EF) | Start norepinephrine infusion. If norepinephrine ineffective, give inotrope (eg, dobutamine). If severe acidemia or bradycardia present, epinephrine may be good second agent. |
| LV poor relaxation (high afterload) | Start norepinephrine infusion. If not contraindicated (eg, ADHF), give discrete boluses isotonic IVF. |
| POCUS assessment RA/RV/IVC/TAPSE | Protect right ventricle as needed |
| Clinical signs of RV dysfunction include JVD, pedal edema, hepatic congestion and ascites | |
| RA and IVC dilated; no septal flattening in diastole | Start norepinephrine infusion. |
| RA and IVC dilated; septal flattening in diastole | Give diuretic (eg, furosemide IV). Start norepinephrine infusion. |
| TAPSE <16 mm + IVV/S' <10 cm | Give inhaled pulmonary vasodilator (eg, inhaled nitric oxide at 40 to 80 ppm; if hypoxemia develops, can reduce dose to 20 ppm). |
| TAPSE/right ventricular systolic pressure <0.31 | Cardiogenic shock present; mechanical circulatory support (eg, Impella device, ECMO) may be needed. |
