Bibliographic information
GuidelineWHO guidelines for the clinical management of filovirus disease
Year of Publication2026
Issuing InstitutionWorld Health Organization
Recommendation
New
WHO suggests that for patients with suspected or confirmed filovirus disease with shock who are being resuscitated with intravenous fluids, vasopressor treatment be initiated early rather than later.
Recommended in favor
Conditional
Certainty of evidence
Low
Notes and Remarks
- This recommendation applies to children and adults, including pregnant women. • Vasopressors should be used within a resuscitation strategy that includes: appropriate intravenous fluid therapy, frequent monitoring, including for arrhythmia, and individualized titration of the dose to desired effect (targeting arterial blood pressure). • The recommendation does not apply to shock caused predominantly by severe dehydration with ongoing gastrointestinal losses, where fluid replacement should be the primary treatment for circulatory insufficiency. Practical info Earlier use of vasopressors is used in combination with more restrictive fluid strategies for resuscitation. These can include (76):
- Lower thresholds for intravenous fluid resuscitation before vasopressor support is considered, for example routine assessment after 1000 mL to 2000 mL has been delivered.
- Adopting strict “rescue criteria” which limits fluid administration after the first 500 mL to specific triggers, for example severe hypotension (systolic blood pressure < 70 mmHg), tachycardia > 130/min, signs of severe hypoperfusion (such as mottled skin or new alteration of consciousness).
- Use of bolus intravenous fluid (250–500 mL) in place of “maintenance therapy” after initial resuscitation, triggered by specific indications such as: plasma lactate ≥ 4.0 mmol/L; MAP < 50 mmHg despite vasopressors; skin mottling; oliguria (urine output < 0.1 mL/kg/hour). Note: this bolus use should be used in addition to fluid to correct ongoing losses, or to correct dehydration where the oral route is not possible.
- Reduction of intravenous fluid in administered medication through use of the oral route, or choice of low-volume alternatives. Use the lowest dose necessary to achieve perfusion target. Check markers of perfusion every 30 minutes.
- In pregnant women and in children, these approaches may not be appropriate: the principles of individualized care based on high-frequency monitoring should be adopted, and specialist advice sought.
- All protocols aim to avoid end-organ hypoperfusion, and required active monitoring and management to do this. In RCTs, vasopressors were initiated after initial intravenous fluid therapy. Protocols varied but early treatment typically initiated norepinephrine after between 1000 mL and 30 mL/kg of initial intravenous fluid had been given. Late administration allowed more liberal fluid use, and typically used repeated boluses to reach a target MAP. In the largest trial, time from randomization to first vasopressor was 1.8 hours in the early group, and 3.2 hours in the liberal fluid group (76).