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  • Critically ill patient, high mortality

  • Emergency surgery, possible full stomach 

  • Distributive shock with severe hypovolemia:

    • Early goal-directed therapy & early antibiotics/source control required 

    • Potential for cardiovascular collapse on induction

    • Need for invasive monitoring 

    • Need for critical care monitoring/ICU postop

  • Multi-organ failure:

    • ARDS

    • AKI

    • DIC





  • Follow Surviving Sepsis Guidelines: 

  • Broad spectrum antibiotics within 1 hour

  • Goal directed resuscitation within 6 hours:

    • MAP ≥ 65 

      • ​Fluid therapy: 

        • ​Use crystalloids as first line, avoid synthetic colloids, consider albumin if substantial amounts of crystalloids used 

        • Initial fluid bolus = 30cc/kg, use dynamic or static variables to guide further fluid therapy 

      • Vasopressors/inotropes:

        • ​Norepinehprine = 1st line 

        • Epinephrine can be added as second vasopressor

        • Vasopressin NOT recommened alone, may be added as second or third agent 

        • Dopamine not routinely recommended 

        • Phenylephrine can be useful if excessive arrythmia from other vasopressor, very high cardiac output states, or as an adjunct vasopressor 

        • Dobutamine as first line inotropic agent in settings of reduced cardiac output/low mixed venous/myocardial dysfunction 

    • Urine output > 0.5 mL/kg/hr

    • Lactate < 2 mmol/L, clearance of lactate

  • Lung protective ventilation (Tidal volumes ~6cc/kg, plateau pressure <30cm H20, PEEP) 

  • Corticosteriods:

    • ​NOT indicated if fluids/vasopressors have restored hemodynamics 

    • Consider IV hydrocortisone 200mg daily if refractory shock 

  • Hemoglobin: in absence of myocardial ischemia/ischemic heart disease, goal Hgb ≥70



*Note that routine monitoring of central venous pressure (CVP) or central venous oxygen saturation (ScvO2) are no longer recommended

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