1. Fluid resuscitation per surgery:
-4 cc of infused isotonic crystalloid equates to 1 cc of increased intravascular volume
-1 cc of 25% albumin infused raises the intravascular volume by 4 cc
-use crystalloids, albumin costs 50x more than NS, and in large trials has not been shown to be superior (SAFE trial)
-Don't use dextrose-fluids intraop, since the stress of surgery leads to increased endogenous glucose release and insulin resistance
-Maintain with D4,0.25NS, with daily BMPs to monitor for hyponatremia or hyperkalemia, which may worsen postop ileus
-Replacement fluids intraop- 3:1 crystalloid:EBL. 1:1 colloids.
2. Too much fluid leads to...
-Hemodilution
-Dilution of clotting factors
-Hypothermia from infusion of unwarmed fluids, which can worsen coagulopathy
-Pulmonary edema (~10L excess)
-Cardiovascular instability (HTN, CHF)
-Poor perfusion at cellular level, poor wound healing
-Bowel edema
3. Selected effects of anaesthesia: 
-Isoflurane leads to increased fluid extravasation, increased third spacing.
-Many anesthetic agents cause myocardial depression, and can push patients in borderline heart failure into frank heart failure
-Spinal anesthesia can cause a chemical sympathectomy, leading to loss of sympathetic tone in venous system, pooling of blood, decreased preload. Treat with fluid before you treat with pressors
4. Transfusion. 
-IN a large meta-analysis of extant trials examining liberal (transfuse when HgB<10) or restrictive (transfuse <7-8) transfusion practices, Carlson et al in a 2012 paper in the [Ann Intern Med] recommend the following guidelines:
-1: The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients (Grade: strong recommendation; high-quality evidence).
-2: The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less (Grade: weak recommendation; moderate-quality evidence).
-3: The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome (Grade: uncertain recommendation; very low-quality evidence).
-4: The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration (Grade: weak recommendation; low-quality evidence).
Generally, the following groups are transfused when Hb<10: Neonates in the NICU, patients with active hemorrhage, and patients with active coronary ischemia symptoms.
5. Pulmonary artery catheters...
...are not associated with survival benefits, or benefits in ICU/hospital length of stay, but are associated with catheter-related complications {Lancet 2005, RCT n=1041} {NEJM 2003, RCT n=1994}
...are associated with increased mortality (OR 1.24), increased cost, and increased ICU LOS SUPPORT study {JAMA 1996, prospective cohort n=5735}
-less invasive way to get information about LVEDV- echo, although inter-rater reliability isn't great
-can be associated with falsely negative reads if the heart is very stiff, or if there is positive pressure ventilation
6. Venous O2 saturation is an earlier sign of shock compared to lactate, other labs. If there is decreased delivery of oxygen to tissues, the tissues will begin to extract more, leading to decreased SvO2. Normal arterial saturation is around 100, normal venous around 80, for an extraction ratio of 20%
7. Sepsis::
-associated with +blood cultures in only 40% of patients
-associated with systemic inflammatory mediators (IL-1, TNF, etc) that lead to vasodilation, increased vascular permeability, and decreased cardiac contractility
-preload, afterload, and contractility are all decreased.
-heart will compensate by increasing HR, combination of that and decreased intrinsic contractility leads to decreased stroke volume. Also, increasing HR will lead to a significant increase in myocardial O2 demand
-overall effect is warm, bounding pulses,
8. Treatments targets for sepsis: (from Surviving Sepsis 2012)
-MAP (best measure of afterload) >65. Below, end organs stop autoregulating pressures.
-CVP 8-12
-Urine output >0.5 cc/kg/hr
-SvO2 >70 (central venous), >65 (S vena cava)
9. Treatments for sepsis: (from Surviving Sepsis 2012)
-Fluids: crystalloids, albumin only if already volume-overloaded with crystalloids.
-Pressors: norepi first choice, epi when you need more, can add vasopressin to norepi for more pression or to decrease norepi dose (not first line), dopamine only if they're low risk for bradycardia/tachyarrythmia, dopamine doesn't protect the kidneys at all according to the data, and does lead to increased risk of arrhythmias.
-Inotropes if the above methods aren't enough and you have evidence of decreased cardiac contractility. Dobutamine 20 mcg/kg/minute
-If everything fails, try steroids (200mg/day, continuous infusion)
-Antibiotics in sepsis: get cultures first, then do broad-spectrum. Particular therapy (i.e. vanc + 4th gen ceph + flagyl vs vanc + b-lactam/b-lactamase) will be dependent on sensitivities and hospital fauna susceptibilities in general.
10. Clindamycin is an effective anti-toxin for tissue-destructive toxins in necrotizing fasciitis. Add it to broad spec antibiotics (not just for nec fasc but also likely staph superinfection), or community acquired MRSA is often suscept to clinda.