In response to the article “Fluids or Pressors in Early Septic Shock?” published in ACEP Now in August 2026, Dr. Joseph R. Shiber commented:
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ACEP Now: September 2026Great article that not only summarizes recent studies but uses physiology as a basis for the mechanisms to support treating the underlying abnormal conditions. I would add that it is very rarely, if ever, a choice of fluids or pressors, but a judicious use of both starting early and adjusting as the patient’s physiology requires.
There are times when a patient presents in severe distributive shock (MAP maybe 40-50 and HR >130) where an IVF bolus and Levophed are both started simultaneously. There are other times where the patient may have severe dehydration (not just third spacing from endotheliopathy of shock) from an underlying condition such as hyperosmolar hyperglycemic state or repeated emesis/diarrhea, along with septic shock where now a large volume crystalloid resuscitation may be required. An individualized approach will always be better than following a cookbook approach based on a population study.
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