Sun28November0628PM 39

A 40-year-old man is admitted to the high dependency unit for pneumococcal pneumonia requiring continuous positive airways pressure (CPAP). Upon reviewing him you are concerned.

Vital signs show a temperature of 38.5°C, heart rate 109/min irregular, blood pressure 90/40 mmHg (mean arterial pressure 60 mmHg), respiratory rate 24/min, SO2 94% on 0.35% FiO2.

Upon assessing volume status, intravenous fluids are being infused at a rate of 166 ml/hour, jugular venous pressure is visible at 6 cm and there is a good urine output.

Invasive monitoring reveals a high cardiac output and very low systemic vascular resistance (SVR). You suspect he is developing sepsis-induced tissue hypoperfusion.

He also appears to be confused; he is unclear where he is presently and unsure of the date.

Which of the following would provide appropriate inotropic support in this patient?

(Please select 1 option)

Dobutamine

Dopexamine

Isoprenaline

Noradrenaline Correct

Milrinone

Explanation

This is a young man with a strong heart who has developed septic shock. Many of his vital signs are consistent with a diagnosis of systemic inflammatory response syndrome (SIRS). He is adequately filled with a good urine output so it is likely that his kidney function will not yet have been affected. However the low SVR reflects peripheral vasodilation secondary to cytokine release and bacteraemia.

Noradrenaline will act to vasoconstrict here and increase pressure. This patient's myocardium should be able to manage the increased preload, however the beta-1 action from noradrenaline will aid myocardial contractility and prevent a drop in cardiac output.

Both dopamine and adrenaline may be used to help increase vascular tone in this situation. However, dopamine is a weak alpha and beta-2 agonist, whereas adrenaline has strong beta-1 action and may induce a tachycardia which, if not managed, may act to reduce optimal tissue perfusion. Therefore, noradrenaline would remain the inotrope of choice here.

Answer Statistics

1

5%

2

2%

3

95%

Times answered: 285