Guidelines recommend initial 30 cc/kg bolus (generally 2L in average adult)
Reassess patient's volume status after initial bolus. Auscultate for pulmonary edema.  Evaluate peripheral circulation.  Consider IVC ultrasound
Septic patients can be euvolemic but remain hypotensive due to vasodilation. Consider early vasopressors.
Increasing evidence that excessive fluid resuscitation can be harmful.
Positive fluid balance on day 3 of hospital admission independently associated with increasing mortality  
Protocolized fluid administration (e.g. traditional Early Goal Directed Therapy) has no mortality benefit over usual care.  
High volume (5+ L) resuscitation associated with increased mortality. 
Consider assessing diastolic dysfunction via echo in CHF patients in whom IVC ultrasound is not reliable
Positive fluid balance on day 3 of hospital admission independently associated with increasing mortality  
Protocolized fluid administration (e.g. traditional Early Goal Directed Therapy) has no mortality benefit over usual care.  
High volume (5+ L) resuscitation associated with increased mortality. 

Indicated if MAP<60 despite adequate IVF or if IVF are contraindicated
Best if given when the vascular space is filled; ok if it is not
Options:
Norepinephrine (5-20mcg/min) - 1st line
Epinephrine (1-20 mcg/min) - 2nd line
Vasopressin (0.03 units/minute fixed dose) can be added to norepinephrine (NE)
as a 2nd line agent may reduce arrhythmia's compared to other pressors with catecholamine properties
Dopamine should be used hesitantly and only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia)
Do not use Low-dose dopamine for renal protection
Dopamine may have increased mortality rates compared to other vasopressors, especially in the pediatric septic patient
Phenylephrine should not be used for treating septic shock except if:
Norepinephrine is associated with serious arrhythmias
Cardiac output is known to be high and blood pressure persistently low
As salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target
Milrinone
Methylene blue consideration for septic shock refractory to catecholaminergic pressors
as a 2nd line agent may reduce arrhythmia's compared to other pressors with catecholamine properties
Do not use Low-dose dopamine for renal protection
Dopamine may have increased mortality rates compared to other vasopressors, especially in the pediatric septic patient
Norepinephrine is associated with serious arrhythmias
Cardiac output is known to be high and blood pressure persistently low
As salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target
Dobutamine (2-20mcg/kg/min) may be added if:
Myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output
Ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP
Beta-2 agonism causes vasodilation, therefore needs to be used in conjunction with vasopressors
Myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output
Ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP
Beta-2 agonism causes vasodilation, therefore needs to be used in conjunction with vasopressors
Controversial and only shown to relieve shock faster in those who have resolution of shock but may increase the risk of infection
Consider hydrocortisone 50-100mg in ED (200-300mg QD in 2-4x/d dosing) if pressor/fluid resistant (SBP < 90 persistently)
ACTH cosyntropin testing likely unreliable in critically ill patients
Do not administer steroids for the treatment of<unk> in the absence of shock
Consider hydrocortisone 50-100mg in ED (200-300mg QD in 2-4x/d dosing) if pressor/fluid resistant (SBP < 90 persistently)
One single-center RCT showing ~40% reduction in mortality when esmolol paired with norepinephrine infusion, with goal HR 80 - 95 BPM
All patients were fluid resuscitated, intubated, given hydrocortisone 300 mg/day
Will require further multi-center RCTs to confirm findings
Sepsis 
Adrenal Insufficiency
Tumor lysis syndrome
Salicylate Toxicity
Hemorrhagic shock
Anticholinergic Toxicity
Toxic shock syndrome
Neuroleptic Malignant Syndrome