Case 1: Venous access in shock
A 45-year-old woman with hypovolemic shock is evaluated for rapid resuscitation in the ICU. She has sickle cell disease with recurrent pain and hemolytic crises, and osteoporosis.
On physical examination, temperature is 39 °C (102.3 °F), blood pressure is 70/40 mm Hg, pulse rate is 142/min and weak, and respiration rate is 22/min. Oxygen saturation is 99% breathing ambient air. There is a subcutaneous port in the right anterior chest wall.
Which of the following is the most appropriate type of venous access for this patient?
A. Intraosseous port
B. Peripheral wide-bore catheter
C. Subcutaneous intravenous port
D. Triple-lumen central catheter
Case 2: Hypotension after fluid resuscitation
A 65-year-old woman is admitted to the ICU with sepsis. She has become increasingly hypotensive despite intravenous fluid resuscitation of 30 mL/kg and the administration of increasing doses of norepinephrine and a standard dose of vasopressin. She has an arterial catheter in place. Appropriate antibiotics have been administered.
On physical examination, temperature is 37.7 °C (100 °F), blood pressure is 88/45 mm Hg, pulse rate is 116/min. Oxygen saturation is 98% on 2 L/min of oxygen through nasal cannula. She is alert and oriented. Her skin is cool. The remainder of the examination is normal.
Telemetry shows premature ventricular complexes.
Which of the following is the most appropriate treatment?
A. Change norepinephrine to dopamine
C. Increase the vasopressin infusion rate
D. Intravenous immune globulin
Case 3: Wound and back pain
A 58-year-old man is evaluated in the hospital for fever, hypotension, and altered mental status. He was hospitalized 2 days ago for an infected arm wound and was treated with intravenous piperacillin/tazobactam and vancomycin. This morning he developed new pain in the middle of his back and difficulty urinating. His medical history is significant for type 2 diabetes mellitus treated with metformin.
On physical examination, temperature is 39.1 °C (102.4 °F), blood pressure is 83/48 mm Hg, pulse rate is 109/min, and respiration rate is 21/min. Oxygen saturation is 98% breathing 2 L/min of oxygen through nasal cannula. He is somnolent but arousable and oriented when awake. There is erythema surrounding the wound on his right upper arm with no drainage or tenderness. There is tenderness to percussion in the middle of his back and a palpable bladder.
Laboratory studies reveal a blood serum leukocyte count of 22,000/µL (22 × 109/L), and plasma glucose of 160 mg/dL (8.88 mmol/L).
Chest radiograph is unremarkable.
Which of the following is the most appropriate next step in management?
A. Intravenous fluid bolus
B. Intravenous insulin
C. MRI of the spine
D. Surgical exploration of the arm wound
Case 4: Flu, tachycardia, hypotension
A 53-year-old man is evaluated in the emergency department after 4 days of cough, fever, chills, myalgia, and poor appetite. He currently has increased dyspnea and lightheadedness. His child was diagnosed with influenza 2 weeks ago.
On physical examination, temperature is 38.8 °C (101.8 °F), blood pressure is 82/40 mm Hg, pulse rate is 128/min, and respiration rate is 17/min. Oxygen saturation is 92% on ambient air. The cardiac examination reveals regular rhythm and tachycardia without an S3 or jugular venous distention. Lungs are clear on auscultation and extremities are warm. The remainder of the examination is normal.
Laboratory studies show hemoglobin 10 g/dL (100 g/L), lactate 4.6 mEq/L (4.6 mmol/L), leukocyte count 18,000/µL (18 × 109/L), and bicarbonate 16 mEq/L (16 mmol/L). Arterial blood gases show pH 7.32, PCO2 32 mm Hg (4.3 kPa), and PO2 70 mm Hg (9.3 kPa).
A chest radiograph shows basilar ground-glass opacities on the right. Electrocardiogram reveals sinus tachycardia but is otherwise normal.
Which of the following is the most appropriate initial treatment?
A. 0.9% saline bolus
B. Intravenous furosemide
D. Packed red blood cells
Case 5: Fever after ICU stay
A 51-year-old man is evaluated for fever, hypotension, and confusion. He was admitted to the ICU 8 days ago for observation after complications resulting from an outpatient surgical procedure. He had experienced unexpected bleeding in the recovery room and had a central venous catheter inserted emergently for blood transfusion. On the first postoperative day he was weaned from mechanical ventilation, vomited once but recovered, and has been receiving supplemental oxygen through nasal cannula. Today he developed a fever, hypotension, and confusion. His hemoglobin has remained stable.
On physical examination, temperature is 38.6 °C (101.5 °F), blood pressure is 89/50 mm Hg, pulse rate is 101/min, and respiration rate is 23/min. Oxygen saturation is 100% on 2L/min of oxygen through nasal cannula. Lung examination reveals clear breath sounds.
Laboratory studies reveal a leukocyte count of 15,000/µL (15 × 109/L) and a serum creatinine of 1.2 mg/dL (106.1 µmol/L).
An intravenous fluid bolus of 30 mL/kg of body weight is now infusing. Blood and respiratory cultures have been obtained and broad spectrum antibiotics are administered.
Which of the following is the most appropriate next step in management?
A. Administer glucocorticoids
B. Administer norepinephrine
C. Obtain procalcitonin level
D. Remove the central venous catheter
Answers and commentary
Correct answer: B. Peripheral wide-bore catheter.
The most appropriate treatment is to insert a peripheral wide-bore catheter. This patient is in shock with several possible causes. Flow of fluid through a catheter is inversely proportional to catheter length and proportional to the radius of the catheter to the fourth power. Therefore, the highest flow rates may be achieved through shorter, large-bore catheters. Peripheral intravenous (IV) catheters are shorter and larger than catheters used for central access or peripherally inserted central catheters and can deliver high volumes of fluid rapidly. For this reason, use of larger, shorter peripheral catheters is preferred for fluid resuscitation in patients requiring emergent treatment. However, peripheral IV catheters can sometimes be difficult to insert in patients in shock, and intraosseous ports and central venous catheters are the alternatives.
Intraosseous ports provide rapid access, but this patient has osteoporosis, which is a contraindication to this method. When used, an initial dose of lidocaine is needed before infusing because pain levels are very high with initial flushes and infusion.
Subcutaneous intravenous ports are long and small bore, which makes them useful for blood draws and small-volume infusion administration but not for rapid, large-volume fluid resuscitation.
A triple-lumen central catheter is an acceptable alternative when no other intravenous access can be obtained; however, it takes longer to insert compared to a peripheral wide-bore catheter. When used, care should be taken to choose wider-bore catheters to overcome the flow restriction from longer lengths.
- Peripheral wide-bore venous catheters are the preferred method for rapid intravenous administration of large amounts of fluids.
Correct answer: B. Hydrocortisone.
Hydrocortisone is the most appropriate treatment. There is controversy about the role of glucocorticoids in the treatment of septic shock, but the Surviving Sepsis Guidelines published in 2016 recommend that if glucocorticoids are used, they should be used in refractory shock with persistent hypotension after adequate fluid resuscitation and after vasopressor medications have been titrated to high dose, and that the dose should be no more than 200 mg of hydrocortisone in 24 hours.
It is unlikely that substituting norepinephrine with another catecholamine vasopressor (dopamine) will lead to increased blood pressure. Dopamine also has a higher risk of inducing cardiac arrhythmias, and in this elderly patient who already has sinus tachycardia and frequent ectopic beats, dopamine would be an inappropriate substitution. Dopamine might best be reserved for selected patients with hypoperfusion and relative bradycardia.
Vasopressin levels in septic shock have been reported to be lower than anticipated for a shock state. Low doses of vasopressin may be effective in raising blood pressure in shock refractory to other vasopressors. Guidelines suggest adding vasopressin (up to 0.03 U/min) to norepinephrine with the intent of raising blood pressure to target or to decrease norepinephrine dosage. Vasopressin is not titrated like other pressors. Higher doses of vasopressin lead to ischemic complications, which more than offset any hemodynamic benefit.
Guidelines currently recommend against the use of intravenous (IV) immunoglobulins in patients with sepsis or septic shock. The most recent systematic review and meta-analysis differentiated between standard polyclonal IV immunoglobulins and M-enriched polyclonal immunoglobulin. Studies included in the review had low to moderate certainty of results based on risk of bias and heterogeneity. After excluding low-quality trials, no survival benefit was discernable with either immune globulin preparation.
- Glucocorticoids are indicated in patients with sepsis who have not achieved hemodynamic stability from intravenous fluid administration and vasopressor therapies.
Correct answer: A. Intravenous fluid bolus.
The most appropriate management is an intravenous fluid bolus of 30 mL/kg of body weight. Successful treatment of severe sepsis and septic shock depends on the rapid institution of hemodynamic support, empiric treatment of infection, and infection control. Crystalloid infusion (normal [0.9%] saline or lactated Ringer solution) to support circulating intravascular volume should be administered to all patients with severe sepsis and septic shock. The 2016 update to the Surviving Sepsis Guidelines recommends using an initial bolus of 30 mL/kg of body weight.
The 2018 American Diabetes Association Standards for Care recommend that insulin therapy be initiated for treatment of persistent hyperglycemia starting at a threshold of 180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140 to 180 mg/dL (7.8 10.0 mmol/L) is recommended for most critically ill and noncritically ill patients. This patient's plasma glucose is not so high that it is an emergency; therefore, administration of insulin is a lower priority than treatment of shock.
This patient may have also have developed a paraspinous abscess (fever, new-onset back pain, difficulty urinating). This patient may need spine imaging but the more urgent priority is his hemodynamic instability, which requires fluid resuscitation before he can undergo any diagnostic imaging study.
Before this patient can be evaluated for surgical source control, he needs to be resuscitated. He is not showing signs of necrotizing fasciitis, which would be a surgical emergency, but even if he were suspected of this diagnosis, he would need aggressive fluid resuscitation while arrangements were made for urgent surgical debridement.
- Patients with hypoperfusion due to sepsis should be managed with aggressive crystalloid fluid resuscitation using an initial bolus of 30 mL/kg of body weight.
Correct answer: A. 0.9% saline bolus.
This patient should receive a 0.9% saline bolus. He has signs of septic shock from influenza (fever, tachycardia, hypotension, elevated leukocyte count, and exposure to influenza). In patients with septic or distributive shock, initial resuscitation efforts should be aimed at giving crystalloid fluids (0.9% saline, Ringer's lactate). The 2016 Surviving Sepsis guidelines recommend giving 30 mL/kg crystalloid solution within 3 hours of presentation in patients who demonstrate signs of tissue hypoperfusion. Judicious fluid administration is warranted thereafter, as intravascular volume overload can contribute to pulmonary edema and pleural effusions. This patient has several features of hypoperfusion, including hypotension, tachycardia, metabolic acidosis, and an elevated blood lactate.
Furosemide would be appropriate if the patient were in cardiogenic shock and presenting with signs of volume overload. The history, examination, and chest radiograph are not consistent with cardiogenic shock or volume overload. Therefore, furosemide is not recommended and would only promote further hypotension.
If hypotension does not rapidly correct with fluids, vasopressors should be titrated to maintain a mean arterial pressure of 65 mm Hg or greater. Norepinephrine is considered first-line therapy. This patient has not received crystalloid solution yet so initial therapy with norepinephrine is incorrect. However, in patients who are refractory to volume loading, vasopressor therapy is recommended to help improve hemodynamic stability.
In the absence of extenuating circumstances (myocardial ischemia, severe hypoxemia, or active hemorrhage), the Surviving Sepsis guidelines recommend that red blood cell transfusion only be given if hemoglobin is less than 7 g/dL (70 g/L). Because this patient has a hemoglobin level above 7 g/dL, there is no direct role for packed red blood cell transfusion.
- Initial treatment of septic or distributive shock should focus on aggressive fluid resuscitation with crystalloids within the first 3 hours of presentation.
Correct answer: D. Remove the central venous catheter.
The most appropriate management for this patient is removal of the central venous catheter. Morbidity and mortality in patients with sepsis are heavily influenced by the care delivered during the first several hours after sepsis onset. Once sepsis is recognized, interventions focus on adequate fluid resuscitation. Crystalloid is recommended at a volume of 30 mL/kg of body weight. In septic shock, mortality increases with each hour that appropriate antibiotic therapy is delayed. Two sets of blood cultures should be obtained before antibiotic infusion in addition to cultures from the suspected infection site. Empiric antimicrobial treatment should cover all suspected pathogens, with special attention to risk factors for resistant or opportunistic organisms, including methicillin-resistant Staphylococcus aureus and Pseudomonas species. Identification and control of the source of infection are critical steps in managing sepsis. This patient may have sepsis due to a central line-associated bloodstream infection. Removal of the emergently placed central venous catheter is the next critical management step.
Glucocorticoid administration is not recommended for patients without shock or who have responded to fluids and vasopressors because it offers no benefit. Some studies suggest that glucocorticoid therapy might benefit patients who remain hypotensive following adequate fluid resuscitation and vasopressor therapy. It is premature to consider administering glucocorticoids to this patient without first assessing the response to the initial resuscitation attempts.
If hypotension does not rapidly correct with fluids, vasopressors should be titrated to maintain a mean arterial pressure of 65 mm Hg or greater. Norepinephrine is considered first-line therapy. Because fluid resuscitation has just been initiated, it is premature to consider vasopressor therapy. If vasopressor therapy is needed, a new intravenous catheter should be placed rather than using the existing catheter, which is suspected as the source of infection.
The biologic marker procalcitonin may help differentiate between bacterial and nonbacterial pneumonia and help exclude a bacterial community-acquired pneumonia diagnosis in outpatients where there is already low suspicion. Procalcitonin level has no evidence-based role in the management of sepsis in the hospital.
- Fluid resuscitation, administration of antibiotics, and infection source control are essential in the early sepsis management.