Personalised fluid therapy in septic shock

Fluid management remains a cornerstone of early septic shock resuscitation; an accumulating body of evidence highlights the substantial risks associated with excessive fluid administration. Fluid overload is consistently associated to organ dysfunction and adverse outcomes, underscoring the need for a personalized approach to intravenous fluid therapy. Over the past decade, research has progressively refined the concepts of fluid responsiveness and the fluid challenge, moving from fixed-volume boluses guided by static measures to individualized, dynamic assessments supported by multimodal monitoring. Recent, large multicenter trials demonstrated that CRT-guided strategies reduce fluid administration, accelerate recovery, and decrease the duration of organ support, despite not significantly affecting mortality. The 2025 European society of intensive medicine Shock Consensus reflects these advances recommending dynamic tests (i.e. mainly passive leg raising and end-expiratory occlusion) for predicting fluid responsiveness, while discouraging reliance on static preload indices and isolated inferior vena cava measurements. The guidelines also emphasize the growing role of mini-fluid challenges, microcirculatory evaluation, and integration of metabolic markers to ensure that increased cardiac output translates into improved tissue perfusion. Personalizing therapy across the four phases of shock (resuscitation, optimization, stabilization, and evacuation) forms the foundation of fluid stewardship. Central to this concept is the optimization phase, where determining the need for continuous monitoring and identifying fluid responsiveness prevent unnecessary fluid administration.