Management of hypertension and hypotension in the emergency department
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Management of Hypertension and Hypotension in the Emergency Department. Hypertension. How do we manage Hypertension in the ER??. Hypertension Management in the ED. Annual Census = 78,000 patients Approximately 215 patients per day

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Hypertension Department

How do we manage Hypertension in the ER??


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Hypertension Management in the ED Department

  • Annual Census = 78,000 patients

  • Approximately 215 patients per day

  • 40 to 50% have elevated BP readings upon admission to the ED

  • That is roughly 39,000 patients/yr with elevated blood pressure readings in the ER.


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First Step: Department

Categorize Types of

Hypertension


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Four Categories of Hypertension Department

- Hypertensive Emergency

- Hypertensive Urgency

- Acute Hypertensive Episode

- Transient Hypertension


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What is a Hypertensive Department

Emergency?


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Hypertensive Emergency Department

- A relative increase in blood pressure from baseline combined with Target Organ Dysfunction (TOD)

  • No Defined Pressure Measurement

  • Target Organ Damage is evident

  • Also known as Hypertensive Crisis or Malignant Hypertension

  • The MOST Serious form of hypertension


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How do we define Department

Target Organ Dysfunction

???


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Target Organ Dysfunction Department

Evidence of Damage or Injury to “Target Organs” such as the Heart, Brain, Lungs, Kidneys, or Aorta.


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Examples of Target Organ Dysfunction Department

  • Acute MI/ Unstable Angina

  • CVA

  • ICH / Subarachnoid Hemorrhage

  • CHF

  • Aortic Dissection

  • Acute Renal Failure

  • Hypertensive Encephalopathy


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How do we determine if Department

Target Organ Dysfunction

is present?


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Evaluation for Target Organ Dysfunction Department

1. EKG: (Evaluation for ST elevation or depression, new T-wave inversions, LVH, or new Left BBB)

  • CXR: (CHF/pulmonary edema, cardiomegaly, widened mediastinum)

  • UA or urine dip: (looking for proteinuria, red cells, or red cell casts)

  • Chem 8: (elevated BUN/CR indicating acute renal insufficiency or failure, look for other etiologies causing mental status changes, like hypoglycemia)

  • Neurological Exam: (Evaluate for lateralizing signs and symptoms)

  • Funduscopic Exam: (looking for papilledema or hemorrhages)

    7. CT Head: (only if neurological findings are suspicious for acute CVA)


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Diagnosis and Management Department

of

Hypertensive Emergency


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Hypertensive Encephalopathy Department

Pathophysiology:

- Loss of Cerebral Autoregulation of blood flow resulting in hyperperfusion of the brain, loss of integrity of the blood brain barrier, and vascular necrosis.

  • Loss of Autoregulation occurs at a constant cerebral blood flow of above MAP 150 to 160 mmHg.

  • Acute Onset

  • Reversible


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Hypertensive Encephalopathy Department

Symptoms:

Headache, Nausea/Vomiting, Lethargy,

Confusion, Lateralizing neurological symptoms

that are not often in an anatomical distribution.

Signs:

Papilledema, Retinal Hemorrhages

Decreased level of consciousness, Coma

Focal neurological findings


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Management of Hypertensive Encephalopathy Department

  • Reduce Mean Arterial Pressure (MAP) by 20 to 25% (T.397) and do not exceed this within first 30 to 60 min.

  • Rosen recommends reduction of 30 to 40% (R.1759)

  • MAP= 1/3(SBP-DBP) + DBP

  • Treatment Reduces vasospasm that occurs at these high pressures

  • Avoid excessive BP reduction to prevent hypoperfusion of the brain and further cerebral ischemia


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Management of Hypertensive Encephalopathy Department

- Nitroprusside is the agent of choice (T.397) and (R.1759)

- Nitroglycerin and Labetalol have been used successfully, but have not replaced Nitroprusside



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Ischemic CVA Department

Pathophysiology:

Elevated Blood Pressure can be the cause of the central nervous system event, OR, it may be a normal physiologic response (Cushing’s Reflex)


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Ischemic CVA Management Department

  • Elevated blood pressure is usually a physiologic response to the stroke itself and NOT the immediate cause

  • This elevation of blood pressure maintains cerebral perfusion to viable but edematous tissue surrounding the ischemic area.

  • Most embolic or thrombotic strokes do NOT have substantial BP elevations and do not need aggressive therapy


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Ischemic CVA Management Department

Management: VERY CONTROVERSIAL!

Recent Trends leans towards NOT treating hypertension in the presence of a Cerebrovascular Accident (thrombotic or embolic) unless Diastolic Blood Pressure exceeds 140mmHg.


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Ischemic CVA Management Department

Tintinelli: Favors lowering MAP (mean arterial pressure) by 20%.

Recommends IV Labetalol in small doses of 5mg increments IF Diastolic Blood Pressure is higher than 140 mmHg.

(T. 398)


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Ischemic CVA Managment Department

Rosen: In most cases, recommends no treatment of Hypertension in CVA patients.

(p. 1760).

- However, the author does recommend treating HTN if diastolic blood pressure is greater than 140 mmHg.


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Management of Department

Hemorrhagic CVA


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Causes of Hemorrhagic CVA Department

  • Hypertensive Vascular Disease

  • Arteriovenous Anomalies (AVM)

  • Arterial Aneurysms

  • Tumors

  • Trauma


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Hemorrhagic CVA Management Department

  • Hypertension associated with hemorrhagic stroke is usually transitory and the result of increased intracranial pressure and irritation of the Autonomic Nervous System


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Hemorrhagic CVA Management Department

  • Hemorrhagic CVA’s commonly results in a profound reactive rise in blood pressure

  • Management is CONTROVERSIAL.

  • Subarachnoid Hemorrhage: oral nimodipine (nimotop) 60mg po q 4 hours to reverse vasospasm. (T.398)

  • Nicardipine: 2mg IV boluses followed by an IV infusion of 4 to 15 mg/hr is used by some to treat Subarachnoid Hemorrhage. (T.398)


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Management of CHF/ Department

Pulmonary Edema


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Congestive Heart Failure / Pulmonary Edema Department

Pathophysiology:

Increased Afterload with decreased Cardiac Output


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CHF / Pulmonary Edema Department

Symptoms:

Shortness of Breath, Cough, Chest Pain

Lower Extremity Swelling

Signs:

Jugular Venous Distension, Rales, S3 Gallop

Hepatomegaly, Pedal Edema


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CHF / Pulmonary Edema Management in the ED Department

  • Nitroprusside or IV Nitroglycerin (T. 398)

  • Rosen: May start with Nitroglycerin, but Nitroprusside is agent of choice if Pulmonary Edema is present. (R. 1760)

  • Attempt treatment of CHF initially with standard agents (Lasix,sublingual NTG, morphine), as these often lower blood pressure, but resort to Nitroprusside if necessary (R. 1761)


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Management of Acute Department

Coronary Syndrome/

Acute MI


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Acute Coronary Syndrome / Department Acute MI

Pathophysiology:

- Increased afterload, cardiac workload, and myocardial oxygen demand

- Decreased coronary artery blood flow


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Acute Coronary Syndrome / DepartmentAcute MI

Symptoms:

Chest Pain, Nausea / Vomiting, Diaphoresis,

Shortness of Breath

Signs:

Congestive Heart Failure Signs,

S4 Gallop

(due to decreased ventricular compliance)

Few physical findings in many patients

Clinical History is very Important


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Acute Coronary Syndrome/ DepartmentAcute MI

  • Immediate Blood Pressure reduction is indicated to prevent Myocardial Damage

  • No specific Defined BP target

  • Tailor treatment to symptom relief

    (T. 398)


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Acute Coronary Syndrome / DepartmentAcute MI

Management:

Nitroglycerin IV or Sublingual (T. 398)

Nitroprusside (T. 398)

Beta Blockers (Esmolol,Lopressor) (T. 356-357)

Nitroglycerin is Drug of Choice (R. 1761)


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Dissection of Department

Thoracic Aorta


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Dissection of Thoracic Aorta Department

Pathophysiology:

- Atherosclerotic Vascular Disease, Chronic Hypertension, increased shearing force on the thoracic aorta, leading to intimal tear.

- 50% begin in ascending aorta

- 30% at aortic arch

- 20% in descending aorta (R.1762-3)


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Dissection of Thoracic Aorta Department

Symptoms:

  • Chest pain radiating to the back (classic presentation)

  • Neurological Symptoms (carotid artery dissection)

  • Angina (coronary artery dissection)

  • Shortness of breath (aortic insufficiency, cardiac tamponade)

    Signs:

    - Differential Blood Pressure (in UE)

  • Bruit (interscapular)

  • Neurological Deficits

  • Acute Cardiac Tamponade (rare)


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Dissection of Thoracic Aorta Department

Management:

  • Medications with negative inotropic effects (beta-blockers) MUST be given FIRST. (reduces shearing force)

  • Vasodilators (nitroprusside) may be added for further antihypertensive treatment after administration of a negative inotropic agent.


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Dissection of Thoracic Aorta Department

Optimal Blood Pressure in these patients is undefined and must be tailored for each patient, however,

SBP of 120-130mmHg may be a intial starting point. (T.408)



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Acute Renal Failure Department

Pathophysiology:

  • Hypertensive Glomerulonephropathy, Acute Tubular Necrosis (ATN)

    - Worsening renal function in the setting of severe hypertension with elevation of BUN/CR, proteinuria, or the presence of red cells and red cell casts in the urine.


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Acute Renal Failure Department

Symptoms:

- Many times there are few actual symptoms

  • Facial or Peripheral Edema due to fluid overload or proteinuria may be present, shortness of breath

    Signs:

  • Few findings unless edematous

  • Pulmonary Edema


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Acute Renal Failure Department

Management:

  • Nitroprusside is agent of choice (T.398)

  • Dialysis (as needed)

  • Rosen: Lasix to enhance Sodium excretion; Also recommends Nitroprusside or Nifedipine (R.1761)

  • Nitroglycerin is also a good agent in this setting since it is hepatically metabolized and gastrointestinally excreted.


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Pheochromocytoma Department


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Pheochromocytoma Department

Pathophysiology:

- Alpha and Beta stimulation of the cardiovascular system due to adrenergic excess states


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Pheochromocytoma Department

Symptoms:

Episodic Headaches, flushing, tremor, diaphoresis, diarrhea, hyperactivity, and palpitations

Signs:

Tachycardia, tachypnea, tremor, hyperdynamic state (high output CHF)


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Pheochromocytoma Department

Management:

  • Alpha Blocker FIRST, followed by a Beta Blocker

  • Phentolamine (alpha) + Esmolol (beta)

  • Labetalol IV (combined alpha and beta blockade)


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Toxemia of Pregnancy Department

Eclampsia/Pre-Eclampsia


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Toxemia of Pregnancy Department

Pathophysiology:

  • Systemic arterial vasoconstriction (including placental, leading to decreased uterine blood flow).

  • Defined as SBP = 140/90 mmHg or greater, OR a 20 mmHg rise in SBP or 10 mmHg rise in DBP from baseline and evidence of HELLP Syndrome


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Toxemia of Pregnancy Department

Symptoms:

Lower extremity swelling, headache, confusion, seizures, coma

Signs:

Edema, hyperreflexia, elevation of blood pressure related to baseline BP prior to pregnancy (elevation may be mild 125/75)


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Toxemia of Pregnancy Department

Management:

  • IV Magnesium Sulfate, Hydralazine.

  • May also use nifedipine or labetalol (R.1762)

  • Delivery of Fetus is definitive treatment of pre-eclampsia


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Summary of Medications used for Hypertensive Emergencies Department

- Intravenous Nitroglycerin:

Start at 0.2 to 0.4 mcg/kg/min (10 to 30 mcg/min) and rapidly increase in 5 to10 mcg/min increments. Titrate to BP and symptomatic improvement. (T.369)

- Nitroprusside:

Start 0.3 mcg/kg/min and titrate up every 5 to 10 minutes based on BP and clinical response. (T.369)

- Esmolol: 500 mcg/kg initial bolus over 1 minute, then start infusion at 50 to 150 mcg/kg/min (T.408)

- Metoprolol (Lopressor): 5mg IV every 2 minutes for a total of 3 doses, then start infusion at 2 to 5 mg/hr. (T.408)


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Summary of Medications used for Hypertensive Emergencies Department

- Labetalol: 20mg IV initial dose, with repeat doses of 40mg to 80mg every 10 minutes to reach desired effect or max dose 300mg. (T. 408)

  • Nicardipine: 2mg IV boluses followed by an IV infusion of 4 to 15 mg/hr

  • Magnesium Sulfate IV: 4 to 6 grams over 15 minutes, followed by IV infusion of 1 to 2 grams/hour

  • Hydralazine: 10 to 20mg IV


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What is a Hypertensive Department

Urgency??


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Hypertensive Urgency Department

- A relative increase in blood pressure from baseline WITHOUT current evidence of TOD, but potential of progression to TOD is HIGH.

- Increased likelihood when pre-existing conditions are present

(renal insufficiency, CAD, CHF)


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Hypertensive Urgency Department

  • Current recommendation is the gradual reduction of blood pressure within 24 to 48 hours by using oral antihypertensive agents

  • Non-compliance is a common cause, therefore, restarting a current regimen of blood pressure medication is appropriate

  • Making needed changes to current blood pressure medication regimens is also appropriate

  • Follow-up within 24 hours should be arranged with Primary Care Physician


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Oral Regimens for Treatment of Hypertensive Department Urgency in the ED

(Tintinelli pg. 402)

  • Clonidine: 0.1 to 0.2mg PO, repeat 0.1mg q hour to desired BP reduction or max of 0.7mg.

  • Labetalol: 200 to 400mg PO, repeat every 2 to 3 hours

  • Captopril: 25mg PO

  • Losartan: 50mg PO


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What is an Acute Department

Hypertensive Episode?


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Acute Hypertensive Episode Department

Elevation of Blood Pressure relative to baseline, but WITHOUT evidence of acute OR impending Target Organ Dysfunction (TOD)


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Management of Acute Hypertensive Episode Department

  • Paucity of evidence that acute intervention in ED is warranted for Hypertensive Episode

  • Complications can occur in acute treatment of patients with chronically elevated blood pressure

  • If HTN is newly diagnosed in the ER, patients should be referred to Primary Care physician for evaluation and initiation of therapy within 24 to 48 hours

  • Again, restarting prior blood pressure medication regimens or adjusting doses is appropriate for patients with previously diagnosed hypertension.


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What is Transient Department

Hypertension??


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Treatment of Transient Hypertension Department

  • Transient HTN occurs in association with other conditions like anxiety, alcohol withdrawal syndromes, toxicological substances, and sudden cessation of medications)

  • Treatment is aimed at underlying cause

  • “White-Coat Hypertension”

  • Single encounter in ED does not warrant diagnosis of HTN or treatment of HTN

  • Follow-up with Primary Care Physician


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SWITCHING GEARS Department


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Hypotension/Shock Department

Management in the ED


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Hypotension/Shock Department

Types of Shock:

-Hypovolemic

(inadequate circulating volume)

- Cardiogenic

(inadequate pump function)

- Distributive

(peripheral vasodilitation)

- Obstructive

(extra-cardiac obstruction of blood

flow)


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Hypotension/Shock Department Goals of Management

1. Determine Cause:

- Usually very apparent

- Can be subtle

- No single Vital Sign that is diagnostic of Shock

- Initial Therapy guided by clinical findings


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Management of Hypotension/Shock Department

2. Evaluate Signs and Symptoms:

- Tachycardia

- Decreased Urine Output

- Cool, Mottled Skin

- Cyanosis

- Confusion


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Hypotension/Shock DepartmentGoals of Resuscitation

ABC’s:

A- Secure Airway (intubate if needed)

B- Insure oxygenation and ventillation

C- Provide Hemodynamic Stabilization (correction of hypotension based on etiology)


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Resuscitation Department

Initiate Fluid Therapy:

0.25 to 0.5 Liters of Normal Saline (NS) or similar isotonic crystalloid should be administered every 5 to 10 minutes as needed for correction of hypotension


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Rapid Fluid Administration Department

It is not unusual for a patient to require 4 to 6 Liters of fluid in the initial phase of resuscitation.


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Goal of Fluid Resusciation Department

  • Stabilization of pt’s mentation

  • Improvement in Blood Pressure

  • Reduction of Pulse Rate

  • Improved Skin Perfusion

  • Urine Output > 30ml per hour


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Inotropic Support Department

If NO response to initial fluid infusion of 3 to 4 L is noted, OR if there are signs of fluid overload (pulmonary edema), Inotropic agents should be started.


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Inotropic Agents Department

  • Dopamine: Start infusion at 5 mcg/kg/min and titrate up to 20 mcg/kg/min in order to achieve desired BP

  • Indicated for reversing hypotension related to AMI, trauma, sepsis, heart failure, and renal failure when fluid resuscitation is unsuccessful or not appropriate (T. 212)


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Inotropic Agents Department

  • Dobutamine: Dosage range is 2 to 20 mcg/kg/min, however, most patients can be maintained at a rate of 10 mcg/kg/min

  • Indicated for cardiovascular decompensation due to ventricular dysfunction or low-output heart failure

  • Agent of choice for management of Cardiogenic Shock

  • Less effect on Heart Rate than Dopamine

    (T. 212)


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Inotropic Agents Department

  • Norepinephrine (Levophed): start infusion at 2 mcg/min and titrate to achieve desired blood pressure.

  • Used when there is inadequate response to other pressors.

  • Lowest dosage that maintains BP should be used in order to minimize the complications of vasoconstriction

  • Increased survival rates of up to 40% in septic shock have been reported in the literature

    (T. 246)


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End Point of Resuscitation Department

  • Normalization of blood pressure, heart rate, and urine output

  • Goal is to maximize survival and minimize morbidity using objective hemodynamic and physiologic values to guide therapy


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Questions ??? Department