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Question 8#

A 64-year-old woman presents to the emergency room with flank pain and fever. She noted dysuria over the past 3 days. Blood and urine cultures are obtained, and she is started on intravenous ciprofloxacin. Six hours after admission, she becomes tachycardic and her blood pressure drops. Her intravenous fluid is NS at 100 mL/h. Her current blood pressure is 79/43 mm Hg, heart rate is 128/minute, respiratory rate is 26/minute and temperature is 39.2°C (102.5°F). She seems drowsy yet uncomfortable. Extremities are warm with trace edema. What is the best next course of action? 

a. Administer IV hydrocortisone at stress dose
b. Begin norepinephrine infusion and titrate to mean arterial pressure greater than 65 mm Hg
c. Add vancomycin to her antibiotic regimen for improved gram-positive coverage
d. Administer a bolus of normal saline
e. Place a central venous line to monitor central venous oxygen saturation

Correct Answer is D

Comment:

This patient is septic, and immediate therapy should be directed at correcting her hemodynamic instability. Patients with sepsis require aggressive fluid resuscitation to compensate for capillary extravasation. This patient’s vital signs suggest decreased effective circulating volume. Normal saline at 100 cc/h is insufficient volume replacement. The patient should be given a saline bolus of 2 L over 20 minutes, and then her blood pressure and clinical status should be reassessed. The elevated respiratory rate could be evidence of pulmonary edema or respiratory compensation of acidosis from decreased tissue perfusion. Even if the patient has evidence of pulmonary edema, fluid resuscitation remains the first intervention for hypotension from sepsis. She is more likely to die from hemodynamic collapse than from oxygenation issues related to pulmonary edema. Stress doses of hydrocortisone and intravenous norepinephrine are both used in patients with shock refractory to volume resuscitation, but should be reserved until after the saline bolus. Vancomycin is a reasonable choice to cover enterococci, which can cause UTI-associated sepsis, but again would not address the immediate hemodynamic problem. If the patient does not improve, a central line (to measure filling pressures and mixed venous oxygen saturation) would allow the “early goal-directed” sepsis protocol to be used.