0071643192.pdf

■ Pancreatitis

■ Ingestions

■ Burns

DIAGNOSIS

■ Based on clinical criteria (see Table 1.16)

TREATMENT

■ Early intubation and mechanical ventilation to decrease work of

breathing

■ Early goal-directed therapy to:

■ Maximize blood pressurethrough use of fluids and/or pressor agents

■ Improve tissue oxygenationthrough cardiac output and oxygen carry-

ing capacity

■ For patients with an SBP < 90 mmHg

■ Insertcentral lineand administer fluids to CVP of 8–12 cm H 2 O.

■ If mean arterial pressure remains < 65 mmHg →beginnorepinephrine.

■ Stimulates α- and β-adrenergic receptors, increasing peripheral vas-

cular tone

■ Alternative agent = dopamine

■ Now measure the central venous oxygen saturation(ScvO 2 ).

■ If<70%→transfuse PRBCsto Hgb concentration of >10 g/dl.

■ If ScvO 2 remains<70%→begindobutamine.

■ Stimulates →β 1 -adrenergic receptors, increases cardiac contractility

and HR with mild dilation of the peripheral vascular bed

■ Early broad spectrum antibiotics

■ Empiric (source unknown)coverage for nonneutropenic patient:

■ Neonates: Ampicillin +cefotaxime

■ Child: Vancomycin +cefotaxime

■ Adult: Vancomycin +imipenem

■ Low-dose corticosteroids if refractory hypotension to treat relative adrenal

suppression

RESUSCITATION

TABLE 1.16 Clinical Criteria for Diagnosis of SIRS and Sepsis

Systemic inflammatory response syndrome (SIRS)

Two or more of the following:

HR > 90 bpm

Temperature < 36°C or > 38°C

RR > 20 breaths/min or PaCO2 < 32 mmHg

WBC ct < 4000 cells/ mm^3 or> 12000 cells/ mm^3 or> 10% immature

neutrophils

Sepsis

SIRS associated with a source of infection

Severe sepsis

Sepsis associated with organ dysfunction, hypoperfusion, or hypotension

Early goal-directed therapy:

Administer fluids to CVP of

8–12 cm H 2 O.

Begin norepinephrine if MAP

remains <65 mmHg.

Transfuse PRBCs to Hgb > 10

g/dL if ScvO 2 <70%.

Begin dobutamine if ScvO 2

remains <70%.

Low-dose corticosteroids are

used to treat relative adrenal

insufficiency in refractory

sepsis.