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Immediate priorities
High-risk biliary obstruction and infection syndromes
Ascending cholangitis with sepsis physiology
Hypotension
Altered mental status
Lactate elevation
Obstructive jaundice with impending cholangitis
Fever absent early
Rising bilirubin over hours to days
Concurrent pancreatitis concern
Epigastric pain radiating to back
Lipase elevation
Immediate escalation triggers
Systolic blood pressure < 90 mmHg after fluids
Vasopressor requirement
Respiratory failure
Oliguria
INR elevation with bleeding concern
Total bilirubin rapidly rising
Monitoring and access
Resuscitation setup
Cardiac monitoring
Continuous telemetry
Frequent blood pressure cycling
IV access
Two large-bore peripheral IVs
Intraosseous access if failed peripheral access
Urine output monitoring
Foley for shock or severe sepsis
Target urine output >= 0.5 mL/kg/hour
Respiratory monitoring
Pulse oximetry
End-tidal CO2 if intubated
Arterial line indications
Vasopressor infusion
Frequent titration needs
Hemodynamic targets and sepsis bundle alignment
Perfusion goals
Mean arterial pressure >= 65 mmHg
Norepinephrine first-line for persistent hypotension
Vasopressin adjunct for escalating norepinephrine requirement
Crystalloid resuscitation for hypoperfusion
30 mL/kg within 3 hours for septic shock physiology
Smaller boluses with frequent reassessment in heart failure
Lactate strategy
Initial lactate
Repeat lactate within 2 to 4 hours if elevated
Early source control planning
Urgent biliary decompression pathway activation
Gastroenterology for ERCP availability
Analgesia and antiemesis
Symptom control framework
Pain control compatible with hemodynamics
Opioid titration with respiratory monitoring
Avoid hypotension-provoking rapid boluses
Antiemetics
Ondansetron IV options
Metoclopramide avoidance in bowel obstruction concern
Early antibiotics and cultures
Sepsis antibiotics workflow
Blood cultures before antibiotics when feasible
Two sets from separate sites
Do not delay antibiotics for difficult access
Antibiotics within 1 hour for septic shock physiology
Broad Gram-negative and anaerobe coverage
Enterococcus coverage in high-risk contexts
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.