Clinically significant hypotension must be correlated with UOP. Adequate end organ perfusion as estimated by UOP 30-50 mL/hr generally requires a MAP >55mm Hg. Persistent oliguria and hypotension should trigger an assessment of the patient’s hemodynamic status and intravascular volume. Reassess for a possible missed injury or ongoing bleeding. Monitor intravascular fluid status using all available technologies. Consider early use of 5% albumin as discussed above as an adjunct.

When available, monitor central venous pressure (CVP); goal CVP is 6-8 mmHg. If CVP is low, increase IV fluid rate. If CVP is at goal but hypotension (Mean Arterial Pressure, MAP < 55mmHg) persists, use vasopressin 0.04 Units/min (do not titrate) followed by norepinephrine (titrate 2-20mcg/min) if needed. Epinephrine and phenylephrine may be used as additional vasopressors in severe shock proven to be non-hemorrhagic. If intravascular volume appears adequate (CVP at goal), STOP increasing IV fluid rate even if oliguria persists. Consider this patient hemodynamically optimized and that the oliguria likely results from an established renal insult. Expect and tolerate some degree of renal dysfunction in large burns. Continued increases in IV fluid administration, despite optimal hemodynamic parameters, will only result in “resuscitation morbidity,” that is often times more detrimental than renal failure.

If the patient exhibits catecholamine-resistant shock, consider the following diagnoses: