Answer: b) Urine output (Merck manual & Handbook of Evidence based critical care)Treatment of shock is directed at maintainingCVP of 8-12 mm HgMean arterial pressure of >65 mmHg (systolic pressure >90 mmHg)Cardiac index of 2-4 L/min/m2The urine output rate should be kept at >0.5 mL/kg per hourAdequate end-organ perfusion is best indicated by urine output of > 0.5 to 1 mL/kg/hHeart 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 mL/kg to maintain hematocrit at 30% or Hb 9 g/dLBolus of 20ml/Kg given rapidly over 5-10 mins; if no response - repeat bolusPatients who do not respond to rapid boluses of 40-60ml/Kg 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 mg/dLFirst 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