A 68-year-old woman with hypertension and hyperlipidemia is admitted with septic shock due to urinary tract infection and gramnegative rod bacteremia. She is treated with 6 L of IV fluids, antibiotics, and norepinephrine up to a dose of 1.5 µg/kg/min. She develops worsening end-organ dysfunction including acute kidney injury requiring renal replacement therapy, acute respiratory failure with hypoxemia requiring intubation, and disseminated intravascular coagulation. On day 3 of her critical illness, she remains on high-dose norepinephrine and mean arterial pressure of 55 mm Hg. In addition to ensuring adequate source control, what is the next best step in her management?
A. Addition of continuous vasopressin infusionCorrect Answer: A
This patient has ongoing septic shock with multiorgan failure despite initial fluid resuscitation and antibiotic therapy. In this setting, the addition of vasopressin to either achieve a mean arterial pressure goal of 65 mm Hg or to reduce the dose of norepinephrine is recommended. Although the trial data are conflicting, empiric addition of corticosteroids in refractory septic shock is recommended. However, cosyntropin stimulation testing has not been demonstrated to identify patients who will benefit from steroids (answer B is incorrect). Although an initial fluid resuscitation with 30 mL/kg of IV fluids is recommended, there are no data for later goal-directed therapy multiple days into a critical illness (answer C is incorrect). Although early hypocaloric enteral nutrition is recommended for patients with sepsis and septic shock, parenteral nutrition either alone or in combination with enteral nutrition is not recommended in patients who can tolerate enteral feeding (answer D is incorrect). Patients with septic shock are at increased risk of acute respiratory distress syndrome and are recommended to receive low tidal volume and lung protective ventilation (answer E is incorrect).
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