Sun21November0452PM 9

A 54-year-old man is being weaned slowly from ventilatory support. He has been on the intensive care unit for the past two weeks with single organ failure.

His blood pressure has dropped over the last four hours and it is now 80/40 mmHg. He has a sinus tachycardia of 120 beats per minute. The oxygen saturation has dropped to 86% on FiO2 0.6 and becomes confused. The peripheries are cool. Air entry is reduced at the right base and his temperature is 34.6°C.

Which of the following options should be performed first?

(Please select 1 option)

Arrange a transthoracic echocardiogram

Arrange a CT pulmonary angiogram

Administer broad spectrum intravenous antibiotics

Perform blood cultures Correct

Commence a noradrenaline infusion

Explanation

This patient has septic shock and early aggressive therapy is indicated with broad-spectrum empirical antibiotics. A pulmonary embolus would account for some of the symptoms, but a more gradual deterioration with systemic inflammatory response (SIRS) response fits more closely with sepsis. The SOFA score in the ICU has a good predictive value in screening for patients likely to have sepsis.

Although vasopressors may be required, fluid resuscitation should occur first.

Although a pulmonary embolus is possible, this will involve a transfer within a hospital. An x ray should be done first, and if a significant PE is strongly suspected, an echocardiogram may give diagnostic information and be more readily available on some intensive care units.

A transthoracic echocardiogram may help exclude a massive pulmonary embolus but this diagnosis is less likely. Blood cultures, antibiotics, fluid, oxygen, lactate and measuring an accurate urine output are higher priorities. If still intubated or has a tracheostomy, a non-directed bronchial lavage may help obtain a sputum sample to help diagnose the offending pathogen, however, the patient may need to be stabilised prior to this.

Fluid resuscitation should occur before inotropes are initiated.

Lung ultrasound and focused intensive care ultrasound would be ideal in this scenario to elucidate the cause of shock. Lung ultrasound would likely demonstrate collapse and consolidation of the right base. In addition, it would help guide fluid resuscitation prior to inotropes.

Reference:

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

Answer Statistics

1

10%

2

6%

3

27%

4

35%

5

25%

Times answered: 276