Five common echocardiographic pitfalls in septic shock

Bedside echocardiography is increasingly used to guide hemodynamic management in septic shock, but its value depends on correct interpretation and integration with the patient’s evolving physiology. This narrative review examines five recurrent pitfalls that may lead to inappropriate fluid administration, delayed recognition of ventricular dysfunction, or suboptimal vasoactive treatment. A focused search of PubMed from database inception through 15 July 2026 and major critical care and echocardiography guidance documents informed the review. The five pitfalls are relying on left ventricular ejection fraction alone; failing to assess right ventricular function systematically; administering fluid without evaluating venous congestion; using static preload indices rather than validated dynamic tests of fluid responsiveness; and treating echocardiography as a single diagnostic event rather than a serial monitoring tool. A structured corrective approach is proposed for each pitfall. Fluid responsiveness, fluid tolerance, and the clinical indication for fluids are treated as separate questions. The review also emphasizes the technical prerequisites of dynamic tests, the limitations of venous excess ultrasound, and the distinction between focused cardiac ultrasound and comprehensive echocardiography. Echocardiography should integrate ventricular function, flow, loading conditions, congestion, and treatment response into a coherent bedside phenotype.