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Chapter 27. Resuscitation: Cooling, Drugs, and Fluids

Brian K Gehlbach, MD
DOI: 10.1378/critcare.21.27
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Sections

Objectives 
  • Discuss the evidence supporting the use of crystalloids over colloids in critically ill patients.

  • Describe hemostatic resuscitation.

  • Cite appropriate endpoints for resuscitation in the management of septic shock.

  • Describe the use of arterial pulse pressure variation, inspiratory changes in central venous pressure, and ultrasonographically assessed respiratory changes in inferior vena cava diameter in determining fluid responsiveness.

  • Describe the uses of waveform capnography during advanced cardiac life support.

  • Describe the use of therapeutic hypothermia following cardiac arrest.

Synopsis 

This chapter reviews selected concepts related to resuscitation. In most ICU settings, there is no advantage to the use of colloids over crystalloids. Contemporary management of traumatic hemorrhage involves the transfusion of red blood cells, plasma, and platelets in a 1:1:1 ratio. Resuscitation of septic shock should be accomplished early and should target the restoration of an adequate intravascular volume, an adequate (≥65 mm Hg) mean arterial pressure, an adequate urine output (≥0.5 mL/kg/h), and either a central venous saturation >70% or a lactate clearance of at least 10% within the first 6 h. Fluid responsiveness in septic shock may be assessed through the assessment of arterial pulse pressure variation in mechanically ventilated patients, the identification of an inspiratory fall in central venous pressure in spontaneously breathing patients, or through the use of bedside ultrasound to assess respiratory changes in inferior vena cava diameter. The best vasoactive drug for shock depends on indication; in general, however, norepinephrine is superior to dopamine for the treatment of shock. The 2010 advanced cardiac life support (ACLS) guidelines emphasize the use of waveform capnography for the confirmation of endotracheal tube position to ensure the quality of CPR and to detect return of spontaneous circulation. Therapeutic hypothermia should be at least considered for all survivors of cardiac arrest. Neurologic prognostication should be more conservative in patients who have been treated with therapeutic hypothermia.

References

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