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Critical Care Medicine

Answer 1
  1. IV fluid bolus. The patient has severe pancreatitis with shock and is developing ARDS and multi-organ failure. Fluid resuscitation is needed at this time. Diuretics (eg, furosemide) would exacerbate hypoperfusion and shock by decreasing intravascular volume. Although the CVP is elevated, numerous studies have shown that CVP is an inaccurate measurement of intravascular volume and fluid responsiveness. Neither CVP nor PAWP provide accurate information regarding the left ventricle’s filling and fluid responsiveness. A better measure of ventricular volume (ie, preload) is bedside echocardiography. For this patient, an empty left ventricle with decreased left ventricular end-diastolic area and end-systolic obliteration with normal or increased contractility would indicate the need for further fluid resuscitation. ß-Blockers would decrease heart rate and blood pressure and worsen CO, which is dependent on tachycardia due to the patient’s low stroke volume (37.5 mL/beat). Occasional ventricular ectopy does not require pharmacologic management, and amiodarone may worsen hypotension. If after receiving adequate IV fluid resuscitation the patient remains hypotensive and in shock, beginning an inopressor would be indicated. However, in the setting of tachycardia and hypotension from pancreatitis or sepsis, dobutamine often worsens hypotension and tachycardia and may precipitate serious cardiac arrhythmias or cardiovascular collapse.1-3

    3. Richard C, Warszawski J, Anguel N, et al. Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome. JAMA 2003;290:2713-20.

    5. Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003;348:5-14.

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