Changing paradigms in surgical resuscitation.

Patients undergoing emergency surgery typically require resuscitation, either because they are hemorrhaging or because they are experiencing significant internal fluid shifts. Intravascular hypovolemia is common at the time of anesthesia induction and can lead to hemodynamic collapse if not promptly treated. Central pressure monitoring is associated with technical complications and does not improve outcomes in this population. Newer modalities are in use, but they lack validation. Fluid resuscitation is different in bleeding and septic patients. In the former group, it is advisable to maintain a deliberately low blood pressure to facilitate clot formation and stabilization. If massive transfusion is anticipated, blood products should be administered from the outset to prevent the coagulopathy of trauma. Early use of plasma in a ratio approaching 1:1 with red blood cells (RBCs) has been associated with improved outcomes. In septic patients, early fluid loading is recommended. The concept of "goal-directed resuscitation" is based on continuing resuscitation until venous oxygen saturation is normalized. In either bleeding or septic patients, however, the most important goal remains surgical control of the source of pathology, and nothing should be allowed to delay transfer to the operating room. We review the current literature and recommendations for the resuscitation of patients coming for emergency surgery procedures.