Critical Care Medicine-Neurologic Disorders>>>>>Shock States
Question 8#

A 34-year-old with quadriplegia secondary to a motor vehicle accident that has been complicated by neurogenic bladder and recurrent urinary tract infections presents to the emergency department with fever, chills, and purulent urine with intermittent straight cath. He is found on presentation to have:

He receives a total of 2500 mL of IV fluids (30 mL/kg) but remains hypotensive. His laboratory tests are notable for a leukocytosis to 18 000/µL with 70% neutrophils and 15% bands. Blood and urine cultures are ordered.

Which of the following is most accurate regarding management of his septic shock?

A. IV fluids should be given to a target central venous pressure of 8 to 12 cm H2O
B. A central venous catheter should be placed to guide further management
C. Lactate should be drawn within 3 hours of presentation
D. Antibiotics should be given immediately
E. He should receive an additional 2500 mL of IV fluid

Correct Answer is C

Comment:

Correct Answer: C

This patient is presenting with septic shock, defined as severe sepsis with persistent hypotension. He has received an initial fluid challenge of 30 mL/kg, and trials that attempted to replicate the improved outcomes originally seen with a central venous target of 8 to 12 cm H2O have failed to demonstrate a benefit (answer A is incorrect). Additionally, if patients with septic shock are randomized to receive a central venous line or not, there does not appear to be a benefit to the placement of a central line. It is recommended that patients with septic shock have an initial lactate drawn within 3 hours of presentation; if the lactate is elevated, it should be repeated within 6 hours of presentation (answer C is correct). Elevated lactate is associated with worse outcomes in septic shock and therefore has prognostic utility. In addition, adherence to checking lactate is associated with better care of sepsis patients, likely because it is a marker for recognition of sepsis. Although the patient should receive prompt antibiotics, it is recommended that blood cultures be drawn before antibiotic administration if it can be done without significantly delaying antibiotics. After initial fluid resuscitation, a repeat evaluation of intravascular volume status and hemodynamics is recommended (answer E is incorrect).

References

The ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370:1683-1693.

Rhodes A, Evans LE, Alhazzani W, et al Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2016. Crit Care Med. 2017;45(3):486-552.

Mikkelsen ME, Miltiades AN, Gaieski DF, et al. Serum lactate is assocaited with mortality in severe sepsis independent of organ failure and shock. Crit Care Med. 2003;37(5):1670-1677.

Centers for Medicare and Medicaid Services, The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures Discharges 10-01-15 (4Q15) Through 06-30-16 (2Q16). http://www.jointcommission.org/assets/1/6/IQRManualRelease Notes_V5_01.pdf