Critical Care Medicine-Neurologic Disorders>>>>>Shock States
Question 2#

A 65-year-old woman with acute myeloid leukemia is undergoing induction chemotherapy as an inpatient. On hospital day 4, she is noted to be hypotensive, febrile, and rigoring. Lactic acid is measured at 5 mmol/L. She is transferred to the intensive care unit (ICU) and her laboratory results from that morning are reviewed. They are notable for an absolute neutrophil count of 120/µL and a creatinine that is elevated to 3 mg/dL from a baseline of 1.2 mg/dL.

Which of the following interventions have been demonstrated to improve mortality for this patient population?

a. Early initiation of renal replacement therapy
b. Early administration of antibacterial agents
c. Procalcitonin-guided antibiotic administration
d. Early administration of systemic antifungal therapy
e. Fluid administration guided by lactic acid

Correct Answer is B

Comment:

Correct Answer: B

This patient is presenting with neutropenic septic shock, a form of distributive shock incited by an infectious etiology. Patients with neutropenic septic shock are at high risk for infection with both resistant gram-negative and gram-positive organisms. Patients in septic shock experience mortality benefit from early administration of appropriate antibiotic therapy (answer B is correct). In the initial 6 hours following the onset of hypotension, every 1-hour delay in antibiotic therapy may be associated with an increase in mortality of greater than 7% in a broad septic shock population.

Timing of renal replacement therapy in septic shock has been examined in several large randomized trials. Routine early renal replacement therapy does not appear to improve outcomes and leads to an increased rate of renal replacement therapy when compared with the later initiation of renal replacement therapy guided by clinical indications (answer A is incorrect). Procalcitonin has been investigated to guide de-escalation of antibiotics in the emergency department and inpatient setting, however does not impact mortality in septic shock (answer C is incorrect). Similarly systemic antifungals are not recommended as first line in septic shock, and their early administration has not been shown to improve mortality (answer D is incorrect). Finally, multiple large multinational randomized trials failed to demonstrate that fluid administration guided by specific biomarkers or resuscitation protocols improved mortality when compared with usual care (answer E is incorrect).

References:

  1. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-1596.
  2. Barbar SD, Clere-Jehl R, Bourredjem A, et al. Timing of renalreplacement therapy in patients with acute kidney injury and sepsis. N Engl J Med. 2018;379(15):1431-1442.
  3. Rowan KM, Angus DC, Bailey M, et al. Early, goal-directed therapy for septic shock – a patient-level meta-analysis. N Engl J Med. 2017;376(23):2223-2234.