A 54-year-old man with ischemic cardiomyopathy (last known ejection fraction 0.4) and coronary artery disease status post prior three-vessel coronary artery bypass grafting presents to his primary care doctor with fatigue and is found to be hypotensive with BP 85/55 mm Hg. He is triaged to the emergency department where he remains hypotensive with initial BP 90/48 mm Hg and is found to be febrile with temperature 39°C with HR 110 beats per minute. He reports fevers at home over the last 48 hours with one episode of rigors. He receives 2 L of IV fluids and is started on norepinephrine.
Which of the following is most accurate regarding placement of a pulmonary artery (PA) catheter in this patient?
Correct Answer: D
Multiple trials have shown no benefit to use of PA catheters in patients with shock; retrospective study data in patients with cardiogenic shock is conflicting with respect to association between PA catheter use and outcomes (answers A and B are incorrect). Additionally, although the early goal-directed therapy was first developed using a PA catheter, there has been no trial that demonstrates that PA catheters increase the likelihood of meeting resuscitation goals in sepsis (answer C is incorrect). However, PA catheters are useful in distinguishing between cardiogenic and vasodilatory shock and are recommended in the management of cardiogenic shock when a vasodilatory or septic component is suspected (answer D is correct). Bleeding complications from PA catheters are uncommon even in critically ill patients (answer E is incorrect).
A 23-year-old man is transferred from another hospital with refractory cardiogenic shock and a diagnosis of fulminant viral myocarditis with an echocardiogram that demonstrated biventricular systolic dysfunction with estimated ejection fraction of 0.15. On arrival to the ICU, he has a PA catheter in place with PA pressures 54/30 mm Hg, a pulmonary capillary wedge pressure of 30 mm Hg, cardiac index 1.8 L/min/m2 , and mixed venous saturation (MVO2 ) of 40%. He has been treated with inotropic support with dobutamine up to a dose of 20 µg/kg/min and diuresis with a continuous high-dose IV furosemide infusion without improvement. His labs are significant for a lactate of 4 mmol/L and a creatinine that has increased from a baseline of 0.8 to 2.6 mg/dL. On examination, his extremities are cold and mottled.
Which of the following is the next best step in managing this patient?
Correct Answer: B
This patient has acute decompensated systolic heart failure and severe cardiogenic shock that has not responded to IV inotrope infusion and diuresis. There are no clear data that one inotrope is superior to another, and because the patient has failed to respond to high doses of dobutamine, it is unlikely that milrinone will have a significantly greater effect (answer A is incorrect). Similarly, although oral bioavailability of bumetanide is more reliable than that of furosemide, there is no evidence that patients with severe cardiogenic shock who have failed to respond to furosemide will have a greater response to bumetanide (answer D is incorrect). This patient does not have evidence of a low systemic vascular resistance, and addition of neosynphrine will simply increase LV afterload and therefore may worsen cardiac function and should be avoided (answer E is incorrect). Although a heart transplant may be considered in nonresolving cardiogenic shock, this patient has a potentially reversible cause of heart failure and needs immediate hemodynamic support (answer C is incorrect). The next best step is therefore initiation of percutaneous mechanical circulatory support to increase cardiac output and improve tissue perfusion (answer B is correct). There are no data to support the use of one mechanical support device over the other, and the support device should be chosen based on local expertise and availability.
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?
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).
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.
A 40-year-old woman with idiopathic pulmonary arterial hypertension on continuous treprostinil has worsening shortness of breath and weight gain of 8 kg in the setting of nonadherence to her home diuretic regimen. On evaluation in the emergency department, she is found to have:
While undergoing other workup, the patient’s respiratory status worsens and the decision is made to intubate her.
Which of the following is most accurate regarding her physiology?
Patients with right heart failure and cardiogenic shock have very tenuous hemodynamics, and intubation presents a uniquely dangerous challenge in this patient population. The combination of induction medications and mechanical ventilation with increased intrathoracic pressures acutely decreases preload to the right ventricle and can increase afterload via an increase in pulmonary vascular resistance with overdistention of the lungs. In addition to avoiding intubation whenever possible, strategies can be undertaken to minimize risk if intubation is unavoidable. Vasopressor support is recommended, and both neosynephrine and vasopressin can preserve right ventricular systolic function by preserving cardiac preload in the setting of vasodilatory induction drugs and by preserving perfusion to the right ventricle and preventing worsening ischemia (answer B is correct). Norepinephrine provides additional inotropic support and is commonly used but there is no high-quality evidence that shows that norepinephrine is superior to other agents (answer D is incorrect).
Although hypercarbia is poorly tolerated, aggressive ventilation with high tidal volumes, high respiratory rate, and high positive end-expiratory pressures can worsen right ventricular afterload by increasing pulmonary vascular resistance, which is lung volume dependent (answer C is incorrect). Propofol is vasodilatory, therefore decreasing preload, and has a potential negative inotropic effect and for those reasons is not a preferred agent in this setting (answer E is incorrect). Etomidate is often recommended, given its smaller effect on hemodynamics. Although an acute decrease in preload is a concern, this patient is already volume overloaded and additional IV fluids are not recommended (answer A is incorrect).
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?
Correct 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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