Sun17October0936AM 6

A 21-year-old man is in the intensive care unit with a diagnosis of meningococcal septicaemia.

His blood pressure has fallen to 70/40 (MAP 50) mmHg despite a noradrenaline infusion running at 0.32 mcg/kg/minute. He is cool peripherally. His lactate is 7 mmol/L, CVP is 6 mmHg and a non-invasive cardiac output monitor shows a cardiac index of 2.4 L/min/m2. His central venous oxygen saturation is 70%.

Which of the following will most effectively improve his clinical status?

(Please select 1 option)

Exploratory laparotomy

Activated protein C

Fluid challenge with crystalloid This is the correct answer

Dobutamine infusion

Intravenous hydrocortisone Incorrect answer selected

Explanation

This patient has shock, with cool peripheries and high lactate. The non-invasive cardiac output monitor suggests a low cardiac index with a high systemic vascular resistance. His central venous oxygen saturation is normal. He is on a high dose of the first line vasopressor. His central venous pressure is low suggesting low preload (which would account for a low stroke volume and therefore cardiac index).

The most effective treatment of the five would be crystalloid boluses.

Activated protein C has no evidence of benefit in sepsis, and has been withdrawn by the manufacturer.

Inotropic support is recommended only for myocardial dysfunction and hypoperfusion despite adequate MAP and intravascular volume. Adequate intravascular volume has not yet been attained.

Lactate is not specific to gut ischaemia, and in sepsis is a marker of general tissue hypoperfusion. There is no other reason in the vignette suggesting the need for laparotomy, and the lactate is probably consistent with septic shock only.

Intravenous hydrocortisone is recommended only for shock refractory to filling and vasopressors. The patient is currently underfilled and this needs to be addressed before corticosteroids are indicated.

Reference:

Surviving Sepsis Campaign. Recommendations: Hemodynamic Support and Adjunctive Therapy.

Answer Statistics

1

1%

2

72%

3

10%

4

19%

Times answered: 262