Assessment of Tissue Perfusion Pressure in Patients With Septic Shock: Beyond Mean Arterial Pressure

OBJECTIVES: Optimization of macrohemodynamics is just the starting point in the management of hemodynamics in patients with septic shock. We describe the interaction between the various determinants of arterial pressure and tissue perfusion, how to optimize them and their estimations at the bedside. This is a concise definitive review of the assessment of tissue perfusion pressure (TPP) in patients with septic shock beyond just mean arterial pressure (MAP). DATA SOURCES: Original publications were retrieved through a PubMed and MEDLINE databases with search terms related to septic shock, arterial blood pressure, critical closing pressure (Pcc), mean systemic filling pressure (Pmsf), and TPP. Supporting evidence was also retrieved from PubMed and MEDLINE when indicated. STUDY SELECTION: English-language systematic reviews, narrative reviews, meta-analyses, randomized clinical trials, and observational studies. DATA EXTRACTION AND DATA SYNTHESIS: Data from relevant publications were reviewed, selected, and summarized by the authors and applied as indicated. CONCLUSIONS: The relationship between arterial pressure and outcomes in septic shock is complex and heterogeneous. Focusing on critical parameters-such as TPP, the vascular waterfall, and individual treatment effects-enables a more personalized approach, focused on perfusion rather than pressure alone. Persistent hypoperfusion despite adequate macrocirculatory targets marks a pivotal moment when microcirculatory assessment becomes essential to guide therapy and avoid potentially harmful escalation of fluids or vasopressors. Bedside measurements of systolic arterial pressure, MAP, diastolic arterial pressure, Pcc, and Pmsf offer practical tools for monitoring and tailoring treatment. Future clinical trials are needed to validate these metrics and refine resuscitation strategies in septic shock.