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Chapter 4: Shock

A 73-year-old man with history of chronic kidney disease and hypertension presented to the hospital with weakness, confusion, and a productive cough. His initial chest x-ray is consistent with a left upper lobe pneumonia, and he is hypotensive on initial examination. Based on his weight of 68 kg, he is fluid resuscitated with 3 Liters of normal saline, and a central line is placed. His white blood cell count is elevated; he has a mild increase in his serum creatinine. His blood pressure subsequently improves and he is started on ceftriaxone and azithromycin after blood and sputum cultures are obtained. He is admitted into the ICU, and on arrival, the nursing staff notes his blood pressure to be 75/58 mmHg with a heart rate of 100 beats/min. A vasopressor is ordered. What is the next best step?

A. Order an echocardiogram to see if he has any evidence of underlying congestive heart failure or wall motion abnormalities suggestive of acute myocardial ischemia.

B. Switch to albumin for further fluid resuscitation as he has already received 3 Liters of normal saline and is hypotensive.

C. Re-examine the patient, assess urine output, and order a bedside ultrasound of the lungs and IVC to assess for fluid responsiveness.

D. Order a CT of the chest, abdomen, and pelvis to ensure adequate source control.

C. Re-examine the patient, assess urine output, and order a bedside ultrasound of the lungs and IVC to assess for fluid responsiveness.

This scenario describes a patient in septic shock who has been appropriately managed with early fluid and antibiotic administration after cultures were obtained. The reoccurrence of hypotension after the initial improvement warrants further attention. The primary question is whether this patient needs more fluid or needs a pressor to be started. While there is no perfect single test to answer this question, using a combination of physical exam findings, ultrasound examination, and invasive or noninvasive assessments of fluid responsiveness is appropriate. While ordering an echocardiogram (choice A) may be appropriate, it will not answer the question of fluid responsiveness by itself. Albumin (choice B) is likely a noninferior choice for fluid resuscitation, but again, we do not know if more fluid administration is appropriate at this time. Finally, obtaining a CT (choice D) may help with source control, but his initial improvement argues against the need for further diagnostics until he is stabilized again.

A 73-year-old man with history of chronic kidney disease and hypertension presented to the hospital with weakness, confusion, and a productive cough. His initial chest x-ray is consistent with a left upper lobe pneumonia, and he is hypotensive on initial examination. Based on his ...

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