Taiwan Crit. Care Med.2009;10: C 1. CVP 8~12 mmhg 2. MAP 65 mmhg 1. 1B

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1 6 24 1C 1. CVP 8~12 mmhg 2. MAP 65 mmhg ml 4. 70% 65% 1 colloid crystalloid 1B SAFE albumin shoalin01@.gmail.com 21

2 p=0.09 prospective meta-analysis 3-5 volume of distribution resuscitation CVP 8 mmhg 12 mmhg 1C hypovolemia ~ ~500 fluid challenge intravascular volume overload hypoperfusion CVP balloon-occluded pressure 1D fluid challenge initial volume expansion period CVP bedside 6,7 venodilationcapillary leak 24 input output / vasopressor MAP 65 mmhg 1C mean arterial pressure auto-regulation 8,9 norepinephrine 65 mmhg 9 65 mmhg norepinephrine dopamine CVP CVP 1C 22

3 catecholamine dopamine epinephrine splanchnic circulation Phenylephrine stroke volume epinephrine dopamine norephinephrine epinephrine Phenylephrine adrenergic agent Dopamine stroke volume heart rate cardiac output stroke volume heart rate dopamine Dopamine Dopamine Dopamine 10 norepinephrine vasopressin 0.03 units/min norepinephrine 2C vasopressin 11 vasopressin ~ dopamine inotropic chronotropic vasopressin hepatosplanchnic flow 18 vasopressin cardiac output dopamine 1A metaanalysis Dopamine placebo peak serum creatinine 19,20 dopamine arterial line 1D pressure cuff 23

4 filling pressure dobutamine 1C dobutamine dobutamine cardiac index 1B dobutamine delivery 21, Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M, Early Goal-Directed Therapy Collaborative Group. Early goaldirected therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345: Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R; SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350: Choi PTL, Yip G, Quinonez LG, Cook DJ. Crystalloids vs. colloids in fluid resuscitation: A systematic review. Crit Care Med 1999;27: Cook D, Guyatt G. Colloid use for fluid resuscitation: Evidence and spin. Ann Intern Med 2001;135: Schierhout G, Roberts I. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: Asystematic review of randomized trials. BMJ 1998;316: Boldt J. Clinical review; hemodynamic monitoring in the intensive care unit. Crit Care 2002;6: Pinsky MR, Payen D. Functional hemodynamic monitoring. Crit Care 2005;9: Hollenberg SM, Ahrens TS, Annane D, Astiz ME, Chalfin DB, Dasta JF, Heard SO, Martin C, Napolitano LM, Susla GM, Totaro R, Vincent JL, Zanotti-Cavazzoni S. Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Crit Care Med 2004;32: LeDoux D, Astiz ME, Carpati CM, Rackow EC. Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med 2000;28: Regnier B, Rapin M, Gory G, Lemaire F, Teisseire B, Harari A. aemodynamic effects of dopamine in septic shock. Intensive Care Med 1997;3: Landry DW, Levin HR, Gallant EM, Ashton RC Jr, Seo S, D Alessandro D, Oz MC, Oliver JA. Vasopressin deficiency contributes to the vasodilation of septic shock. Circulation 1997;95: Patel BM, Chittock DR, Russell JA, Walley KR. Beneficial effects of short-term vasopressin infusion during severe septic shock. Anesthesiology 2002;96: Dunser MW, Mayr AJ, Ulmer H, Knotzer H, Sumann G, Pajk W, Friesenecker B, Hasibeder WR. Arginine vasopressin in advanced vasodilatory shock: a prospective, randomized, controlled study. Circulation 2003;107: Malay MB, Ashton RC, Landry DW, Townsend RN. Low-dose vasopressin in the treatment of vasodilatory septic shock. J Trauma 1999;47: Holmes CL, Walley KR, Chittock DR, Lehman T, Russell JA. The effects of vasopressin on hemodynamics and renal function in severe septic shock: a case series. Intensive Care Med 2001;27: Lauzier F, Levy B, Lamarre P, Lesur O. Vasopressin or norepinephrine in early hyperdynamic septic shock: a randomized clinical trial. Intensive Care Med 2006; 32:

5 17. Sharshar T, Blanchard A, Paillard M, Raphael JC, Gajdos P, Annane D. Circulating vasopressin levels in septic shock. Crit Care Med 2003;31: Dunser MW, Mayr AJ, Tur A, Pajk W, Barbara F, Knotzer H, Ulmer H, Hasibeder WR. Ischemic skin lesions as a complication of continuous vasopressin infusion in catecholamine-resistant vasodilatory shock: incidence and risk factors. Crit Care Med 2003;31: Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J. Low-dose dopamine in patients with early renal dysfunction: a placebocontrolled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet 2000;356: Kellum J, Decker J. Use of dopamine in acute renal failure: a meta-analysis. Crit Care Med 2001;29: Gattinoni L, Brazzi L, Pelosi P, Latini R, Tognoni G, Pesenti A, Fumagalli R. A trial of goal-oriented hemodynamic therapy in critically ill patients. N Engl J Med 1995;333: Hayes MA, Timmins AC, Yau EH, Palazzo M, Hinds CJ, Watson D. Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med 1994;330:

6 HEMODYNAMIC SUPPORT: FLUID THERAPY, VASOPRESSOR AND INOTROPICS Shoa-Lin Lin Abstract Despite spectacular advances in life-support technology, the management of patients with severe sepsis continues to be a significant health care challenge because of the associated major morbidity and high mortality. Standard therapy for patients with septic shock includes antibiotics, infection source control, and hemodynamic support with fluids and vasoactive medications. Early goal-directed resuscitation has been shown to improve survival for emergency department patients presenting with septic shock in a randomized, controlled study. Resuscitation directed toward the early goals for the initial 6-hr period of the resuscitation has been reported to be able to reduce 28-day mortality rate. This report focuses on the fluid therapy, vasopressor and inotropic supports. Other portions of management of patients with severe sepsis will be introduced by other specialists. Key words: Fluid therapy, Hemodynamic, Inotropics, Sepsis, Vasopressor Correspondence: Dr. Shoa-Lin Lin Intensive Care Unit, Kaohsiung Veterans General Hospital, No.386, Ta-Chung 1st Rd., Kaohsiung City813, Taiwan, Phone: ; Fax: ; shoalin01@gmail.com 26