›Core measures
›NPO status
›Aspiration reduction
›Operative readiness
›IV access
›Two large-bore peripheral IV lines
›Central venous access if vasopressors needed (Class I, expert consensus)
›Gastric decompression
›NG tube for persistent vomiting or obstruction concern
›Avoid routine NG if no vomiting and no obstruction concern
›Analgesia strategy
›Opioid titration to comfort
›Avoid NSAIDs in suspected ulcer perforation
›Antiemetic strategy
›Ondansetron or alternative
›QT risk awareness
›Resuscitation hemodynamics
›Crystalloid
›Balanced crystalloid preferred in sepsis (Class IIa, expert consensus)
›Initial bolus 500-1000 mL with reassessment
›30 mL/kg reference strategy in shock (Class I, sepsis consensus)
›Vasopressor escalation
›Norepinephrine infusion as first-line (Class I, sepsis consensus)
›Initiate 0.05-0.1 mcg/kg/min
›Titrate every 2-5 minutes to MAP >= 65 mmHg
›Typical range 0.05-1 mcg/kg/min
›Peripheral administration acceptable short term with proximal IV and monitoring (Class IIa, expert consensus)
›Frequent site checks for extravasation
›Transition to central access when feasible
›Vasopressin adjunct
›Add if escalating norepinephrine (Class IIa, sepsis consensus)
›0.03 units/min fixed dose
›Not titrated
›Epinephrine adjunct
›Add if refractory shock (Class IIb, sepsis consensus)
›Initiate 0.02-0.05 mcg/kg/min
›Titrate to MAP target
›Empiric intra-abdominal coverage
›Timing
›Within 1 hour in septic shock (Class I, sepsis consensus)
›Within 3 hours in sepsis without shock (Class I, sepsis consensus)
›Community-acquired high-risk or severe infection
›Piperacillin-tazobactam 4.5 g IV every 6 hours
›Renal dose adjustment when eGFR reduced
›Extended infusion strategy per local protocol
›Cefepime 2 g IV every 8 hours
›Add metronidazole 500 mg IV every 8 hours
›Neurotoxicity risk in renal dysfunction
›Meropenem 1 g IV every 8 hours
›Reserve for ESBL risk or severe healthcare exposure
›Renal dose adjustment required
›Community-acquired lower-risk and stable
›Ceftriaxone 2 g IV daily
›Add metronidazole 500 mg IV every 8 hours
›Suitable for many perforated appendicitis or diverticulitis cases
›Ertapenem 1 g IV daily
›Option for mixed flora coverage without Pseudomonas coverage
›MRSA coverage indications
›Prior MRSA colonization or infection
›Severe healthcare-associated exposure
›Abdominal wall mesh infection concern
›Vancomycin IV weight-based dosing per local protocol
›Loading 20-25 mg/kg actual body weight in shock
›Maintenance guided by levels and renal function
›Antifungal coverage indications
›Upper GI perforation with severe illness
›Recent abdominal surgery or anastomotic leak
›Immunocompromised
›Fluconazole 800 mg IV load
›Then 400 mg IV daily
›Avoid if high azole resistance concern
Source control and operative pathway
›Surgical management
›Early surgery involvement (Class I, expert consensus)
›Generalized peritonitis
›Free perforation on imaging
›Time-to-source-control priority (Class I, sepsis consensus)
›As soon as feasible after stabilization
›Do not delay for complete normalization of vitals
›IR drainage pathway
›Abscess without generalized peritonitis
›Hemodynamic stability with contained process
›Nonoperative pathway selection
›Contained perforation on CT
›No diffuse peritoneal signs
›Close monitoring resources available
›Stress ulcer and upper GI perforation adjuncts
›Pantoprazole 80 mg IV bolus
›Then 8 mg/hour infusion for high-risk bleeding concern
›Alternative pantoprazole 40 mg IV every 12 hours if no bleed concern
›Antiemetics
›Ondansetron 4 mg IV
›Repeat every 6-8 hours as needed
›QT prolongation risk
›Metoclopramide 10 mg IV
›Avoid in obstruction suspicion
›Extrapyramidal symptom risk
›Analgesia
›Fentanyl 25-50 mcg IV
›Repeat every 5-10 minutes to effect
›Lower histamine release profile
›Hydromorphone 0.2-0.5 mg IV
›Repeat every 10-15 minutes to effect
›Caution in older adults
›Morphine 2-4 mg IV
›Repeat every 10-15 minutes to effect
›Histamine and hypotension risk