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Difficulty: MediumGeneral Internal Medicine

A 62-year-old woman is evaluated in the emergency department for a 24-hour history of confusion and fever. She was brought from a skilled nursing facility where she is recovering from an ischemic stroke. Her medical history includes chronic obstructive pulmonary disease (COPD) and diet-controlled type 2 diabetes mellitus. Medications include aspirin and inhaled tiotropium.

Vital signs are temperature 38.6°C (101.5°F), blood pressure 82/50 mm Hg, pulse 122/min, and respirations 24/min. Pulse oximetry is 94% on room air.

Physical examination reveals a lethargic and disoriented patient. Mucous membranes are dry. Lung auscultation reveals mild, diffuse end-expiratory wheezing without crackles. Cardiac examination shows tachycardia with a regular rhythm. The abdomen is soft, but right costovertebral angle tenderness is present.

Laboratory results are as follows:
Leukocytes: 16,500/mm³ (15% bands)
Sodium: 138 mEq/L
Potassium: 4.8 mEq/L
Bicarbonate: 16 mEq/L
Creatinine: 2.1 mg/dL (baseline 0.9 mg/dL)
Lactate: 4.2 mmol/L
TSH: 0.1 mU/L (Normal 0.4-4.0 mU/L)
Free T4: 0.6 ng/dL (Normal 0.9-1.7 ng/dL)

Arterial blood gas on room air:
pH: 7.30
PaCO2: 32 mm Hg
PaO2: 78 mm Hg

A urine culture collected 2 days ago at the nursing facility for dysuria has just resulted, showing >100,000 CFU/mL of *Escherichia coli* sensitive to ceftriaxone, ciprofloxacin, and nitrofurantoin.

A chest radiograph shows hyperinflated lungs and flattened diaphragms with no focal consolidations or pulmonary venous congestion.

The patient is immediately started on intravenous ceftriaxone. Over the next 2 hours, she receives 3 liters of intravenous normal saline. Reassessment shows a blood pressure of 78/48 mm Hg and a pulse of 118/min.

Which of the following is the most appropriate next step in management?

  1. Initiate intravenous norepinephrineAnswer
  2. B
    Switch antibiotic therapy to intravenous meropenem
  3. C
    Administer intravenous furosemide
  4. D
    Administer intravenous sodium bicarbonate
  5. E
    Initiate intravenous levothyroxine

Answer

Initiate intravenous norepinephrine
This patient is presenting with septic shock secondary to acute pyelonephritis. According to Surviving Sepsis Campaign guidelines, initial resuscitation for sepsis with hypotension or a lactate ≥ 4.0 mmol/L requires rapid administration of at least 30 mL/kg of intravenous crystalloids. This patient received 3 liters of normal saline (adequate for an average adult) but remains profoundly hypotensive with a blood pressure of 78/48 mm Hg (Mean Arterial Pressure [MAP] = 5858 mm Hg). For fluid-refractory septic shock, the immediate next step is the initiation of vasopressors to maintain a MAP ≥65\geq 65 mm Hg. Norepinephrine is the first-line vasopressor of choice.

Step-by-Step Solution

1
Diagnose the primary condition
The patient has septic shock secondary to pyelonephritis, evidenced by fever, CVA tenderness, leukocytosis, positive urine culture, lactic acidosis, and severe hypotension.
Identifying the etiology of the shock state is necessary to guide appropriate resuscitation and antimicrobial therapy.
2
Evaluate the response to initial therapy
The patient received 3 liters of intravenous crystalloid (standard 30 mL/kg fluid challenge for sepsis), but her blood pressure remains 78/48 mm Hg (MAP = 58 mm Hg).
Hemodynamic reassessment determines if the patient is fluid-responsive or fluid-refractory.
3
Determine the next pharmacological intervention
Initiate a vasopressor (norepinephrine) to achieve a target MAP of ≥ 65 mm Hg.
In fluid-refractory septic shock, vasopressors are indicated immediately after adequate fluid resuscitation to prevent prolonged organ hypoperfusion.

Key Concept

Management of fluid-refractory septic shock
Estimated Time:1m 30s
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Topics

General Internal Medicine

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