Question

An intensive care unit team is called to evaluate a female patient, aged $67$, due to profound hypotension and worsening mentation. She was admitted through the emergency department earlier today after her family found her difficult to arouse. Her medical history includes a mechanical mitral valve replacement performed $5$ years ago (managed with chronic warfarin therapy) and frequent urinary tract infections. Of note, she finished a $7$-day regimen of oral ciprofloxacin $2$ weeks prior for acute cystitis.

Initial assessment in the emergency department revealed a core temperature of $39.2^\circ\text{C}$ ($102.5^\circ\text{F}$). Urinalysis was markedly abnormal, showing positive nitrites, leukocyte esterase, and $>50$ leukocytes per high-power field. She was given $30$ mL/kg of intravenous balanced crystalloid solution over a $2$-hour window.

Current parameters in the ICU show:
Temperature: $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$)
Blood pressure: $76/44$ mm Hg
Heart rate: $142$/min with an irregularly irregular rhythm
Respiratory rate: $24$/min
Oxygen saturation: $95\%$ on room air

A 12-lead electrocardiogram confirms atrial fibrillation with rapid ventricular response.

Pertinent laboratory data include:
Leukocytes: $18,500$/mm $^3$
Hemoglobin: $11.2$ g/dL
Platelets: $165,000$/mm $^3$
Serum creatinine: $2.1$ mg/dL (recent baseline was $0.9$ mg/dL)
Serum lactate: $4.8$ mmol/L
INR: $1.7$ (established target range for her valve prosthesis is $2.5$-$3.5$)

Blood and urine cultures are incubating.

Which of the following intravenous pharmacologic interventions are appropriate to administer at this time? (Select all that apply)