Management of Complicated Diverticulitis
Annotation for Point F
This will take 2 to 3 hours to accomplish. The patients are administered a bolus of 20 mL/kg of isotonic crystalloids and given rescue norepinephine as needed to maintain a mean arterial pressure more than 65 mm Hg. Broad-spectrum antibiotics are administered. At least two large-bore intravenous lines are needed. Given that the patient is in septic shock, a central line (via the internal jugular vein placed under ultrasound guidance) and an arterial line are placed. With ongoing volume loading, CVP is increased to more than 10 cm H2O. At this point, the patient is intubated. Avoid etomidate as an induction agent because it is known to suppress the adrenal function and its use in critically ill patients is associated with increased mortality.20 Use ketamine instead because it does not adversely affect cardiac function and it down-regulates proinflammation.21 Ventilation is then optimized. Norepinephrine is titrated to maintain a mean arterial pressure of more than 65 mm Hg, and if high doses are required, stress dose steroids are administered.15 Electrolyte abnormalities are corrected, and blood products are administered based on institutional guidelines. Lactate and mixed venous hemoglobin saturations are measured.