**2.4 Rapid restoration of perfusion (first three hours)**

Aggressive administration of intravenous fluids, usually crystalloids given at 30 ml/kg, started by one hour and completed within the first 3 hours following presentation.

Some patients may require higher than recommended volumes, particularly those who demonstrate clinical and/or hemodynamic indicators of fluid-responsiveness. The clinical and hemodynamic response and the presence or absence of pulmonary edema must be assessed before and after each bolus using passive leg raising, CVP variation, ScvO2, pulsed pression variation (PPV) or ultrasound indicators etc.… Intravenous fluid challenges can be repeated until blood pressure and tissue perfusion become acceptable.

#### **2.5 Vasopressors**

Vasopressors on CVC if the blood volume is optimized and persistent hypoperfusion or immediately if the diastolic blood pressure is less than 40 mmHg.

Based on the SSC (survival sepsis campaign) guidelines 2016 [5], the response should be assessed using the following targets within 6 hours: ScvO2 ≥ 70%, CVP 8–12 mmHg, mean arterial pressure (MAP) ≥65 mmHg, and urine output ≥0.5 ml/kg/hour.
