ESICM guidelines on circulatory shock and hemodynamic monitoring 2025

Abstract

Objective: These European Society of Intensive Care Medicine (ESICM) guidelines provide recommendations for the diagnosis of shock and hemodynamic monitoring for adult critically ill patients.

Methods: An international panel of experts formulated PICO-formatted questions, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to assess evidence and formulate recommendations. In the absence of strong evidence, panelists issued ungraded good practice statements (UGPS).

Results: Panelists issued 50 statements. Among others, skin perfusion should be monitored using the assessment of capillary refill time, and this may be complemented by the assessment of skin temperature and mottling (UGPS). In patients with a central venous catheter, serial measurements of (central) venous oxygen saturation and of the veno-arterial difference in carbon dioxide partial pressure should be performed (UGPS). In patients with persistent shock after initial fluid resuscitation, fluid responsiveness should be assessed before continuing fluid resuscitation (UGPS). It is recommended to use dynamic variables over static markers of preload for predicting fluid responsiveness, when applicable (graded statement). Cardiac output (CO) and/or stroke volume should be monitored in patients who do not respond to initial therapy (UGPS). Arterial pressure should be monitored with an arterial catheter in shock that is not responsive to initial therapy and/or requiring vasopressor infusion (UGPS), and central venous pressure should be measured in patients who have a central venous catheter (UGPS). Panelists suggest using echocardiography as the first-line imaging modality to assess the type of shock (graded statement). Echocardiographically defined phenotypes of left and right ventricular dysfunction may be of prognostic significance (UGPS).

Conclusions: The panel made 50 recommendations on shock diagnosis and hemodynamic monitoring.

Keywords: Acute circulatory failure; Arterial pressure; Capillary refill time; Cardiac output; Central venous pressure; Echocardiography; Fluid responsiveness; Fluid therapy; Intra-abdominal pressure; Lactate; Microcirculation; Practice guidelines; Vasopressors; Venous oxygenation.