A 72-year-old woman is evaluated in the surgical intensive care unit for new-onset fever a… — USMLE Step 2 CK

A $72$ -year-old woman is evaluated in the surgical intensive care unit for new-onset fever and hypotension. She is currently on postoperative day $6$ following an exploratory laparotomy and small bowel resection for mesenteric ischemia. Her past medical history includes ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$ , and type $2$ diabetes mellitus. She has been receiving parenteral nutrition via a right internal jugular central venous catheter that was placed prior to her surgery.

Over the past $6$ hours, her temperature has risen to $39.4^\circ\text{C}$ ( $102.9^\circ\text{F}$ ), heart rate to $122\text{/min}$ , and blood pressure decreased to $85/50\text{ mm Hg}$ . Her urine output has dropped to $10\text{ mL/h}$ over the last $4$ hours.

Physical examination reveals a lethargic patient. Jugular venous pressure is estimated at $3\text{ cm H}_2\text{O}$ . The lungs are clear to auscultation bilaterally. The abdomen is mildly distended but non-tender, with a clean, intact midline surgical incision. Inspection of the right internal jugular catheter site reveals $2\text{ cm}$ of surrounding erythema and purulent exudate at the insertion site.

Laboratory studies:
Leukocyte count: $21,000\text{/mm}^3$ ( $85\%$ neutrophils, $10\%$ bands)
Serum creatinine: $2.1\text{ mg/dL}$ (baseline $1.1\text{ mg/dL}$ )
Blood lactic acid: $4.2\text{ mmol/L}$

Blood and urine cultures have been obtained. Which of the following are appropriate next steps in the management of this patient? (Select all that apply)

Removal of the right internal jugular central venous catheterAnswer
Administration of a rapid intravenous crystalloid bolusAnswer
C
Initiation of broad-spectrum monotherapy with intravenous meropenem
D
Administration of intravenous furosemide
E
Computed tomography scan of the abdomen and pelvis with intravenous contrast

Answer

The appropriate next steps in management are the removal of the right internal jugular central venous catheter and the administration of a rapid intravenous crystalloid bolus.

The correct interventions are removing the infected central venous catheter and administering an intravenous crystalloid bolus. The patient is in septic shock secondary to a clinically obvious Central Line-Associated Bloodstream Infection (CLABSI), indicated by fever, hypotension, and purulence at the catheter site. Management of septic shock requires immediate hemodynamic resuscitation. Although the patient has a history of ischemic cardiomyopathy, her physical examination (low jugular venous pressure, clear lungs) confirms severe absolute and relative hypovolemia. Therefore, a rapid crystalloid bolus is necessary to restore organ perfusion. Simultaneously, source control is paramount; the infected catheter must be removed immediately, and the tip should be sent for culture.

Step-by-Step Solution

Assess the patient's hemodynamic status and etiology of deterioration.

The patient presents with fever, tachycardia, hypotension, oliguria, and elevated lactate on postoperative day 6, indicative of septic shock.

Identifying the type of shock is critical for determining the initial resuscitation strategy.

Evaluate the patient's volume status in the context of her comorbidities.

Despite a history of ischemic cardiomyopathy (LVEF 35%), the low jugular venous pressure (3 cm H2O) and clear lung fields confirm profound hypovolemia rather than cardiogenic shock or fluid overload.

Accurate volume assessment prevents inappropriate administration of diuretics and confirms the need for aggressive fluid resuscitation.

Identify the source of infection based on physical examination.

The presence of a purulent exudate and erythema at the central venous catheter insertion site strongly points to a Central Line-Associated Bloodstream Infection (CLABSI).

Source identification directs both mechanical source control (catheter removal) and targeted empiric antimicrobial therapy.

Determine the immediate sequence of interventions.

The most urgent interventions are fluid resuscitation with an intravenous crystalloid bolus and immediate removal of the infected central venous catheter.

Simultaneous hemodynamic stabilization and source control are the cornerstones of managing septic shock.

Key Concept

In a patient presenting with septic shock and a suspected central line-associated bloodstream infection (CLABSI), immediate management must include aggressive intravenous fluid resuscitation (irrespective of baseline heart failure if clinical signs show hypovolemia) and prompt mechanical source control via catheter removal.

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