<prompt> A patient with burns presents to the emergency room. He was started on intravenous fluids. The best method to assess the adequacy of volume replacement isPulse rateUrine outputSystolic blood pressureCentral venous pressure  <response>: Answer: b Urine output Merck manual Handbook of Evidence based critical careTreatment of shock is directed at maintainingCVP of 8-12 mm HgMean arterial pressure of 65 mmHg systolic pressure 90 mmHgCardiac index of 2-4 Lminm2The urine output rate should be kept at 0.5 mLkg per hourAdequate end-organ perfusion is best indicated by urine output of 0.5 to 1 mLkghHeart rate, mental status, and capillary refill may be affected by the underlying disease process and are less reliable markers.Because of compensatory vasoconstriction, mean arterial pressure MAP is only a rough guideline; organ hypoperfusion may be present despite apparently normal values.An elevated arterial blood lactate level reflects hypoperfusion; however, levels do not decline for several hours after successful resuscitation.HEMODYNAMIC SUPPORT IN SHOCKNS or RL crystalloids is the first choice for acute stage of resuscitationWhen fluid requirements are high, colloids Dextran, gelatin, 5 albumin are of usePacked RBC should be given at 10 mLkg to maintain hematocrit at 30 or Hb 9 gdLBolus of 20mlKg given rapidly over 5-10 mins; if no response - repeat bolusPatients who do not respond to rapid boluses of 40-60mlKg in the first hour are labeled as fluid refractory shock and inotrophic support dopamine or dobutamine should be givenUse insulin only if it is needed to maintain the blood glucose concentration below 150 mgdLFirst line Vasopressor inAnaphylactic shock: EpinephrineSeptic shock, Cardiogenic shock, Vasodilatory shock: NorepinephrineRefractory shock: EpinephrineIf shock persists - catecholamine resistant shock - give Hydrocortisone if adrenal insufficiency is suspectedACTH stimulation test is not useful for detecting less profound degrees of corticosteroid deficiency in patients who are critically illVasodilators nitroprusside, nitroglycerine in children remaining hypodynamic with high SVR despite fluid and ionotropic supportChildren remaining normotensive with low output state and high SVR despite epinephrine and vasodilator - phosphodiesterase III inhibitors Amrinone, Milrinone are givenRecombinant activated protein C aPC - for severe sepsis or septic shock 