A 55-year-old woman is hospitalized for shortness of breath, productive cough, and pleuritic chest pain. Her medical problems include major depression and schizophrenia, and her medications are unknown. In the emergency department, her trachea is intubated due to respiratory distress, a right internal jugular catheter is placed, and normal saline is administered as repeat boluses. In the intensive care unit, her temperature is 38.9 C (102 F), blood pressure is 85/42 mm Hg, and pulse is 115/min. The patient's pulse oximetry shows 90% on assist-control mode with a respiratory rate of 16/min, tidal volumes of 470 mL, fraction of inspired oxygen of 70%, and positive end-expiratory pressure of 10 cm H₂0. Examination shows bibasilar crackles and normal first and second heart sounds. The abdomen is soft and nontender. There is no peripheral edema. The extremities are warm to the touch with faint pulses. Mean central venous pressure is 14 mm Hg. Laboratory results are as follows: Chest x-ray shows bilateral diffuse alveolar opacities. Which of the following interventions is the best next step in management of this patient?

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11ec193a_971a_8d7e_853d_09ccec04349a_MD0002_00 This patient has septic shock, possibly due to pneumonia. Important aspects of sepsis management include adequate fluid resuscitation, timely antibiotic administration and infectious source control (eg, drainage of abscess), and frequent clinical assessment of adequacy of circulation (eg, mean arterial pressure, urine output, mental status). Although approaches such as early goal-directed therapy (central venous pressure of 8-12 mm Hg, mean arterial pressure >65 mm Hg, central venous oxygen saturation >70%, and urine output >0.5 mL/kg/hour) have become popular in practice, the optimal targets are unknown and the benefit of measuring these physiologic variables is controversial. In a patient with septic shock, adequate fluid boluses (optimal volume unknown) should be administered before instituting vasopressor support. Most patients require at least 2 L, and a typical target for pulmonary capillary wedge pressure (if measured) is 12-14 mm Hg. If hypotension persists, current guidelines recommend norepinephrine as a first-line agent. Norepinephrine acts on α1 and β1 receptors, leading to potent vasoconstriction and a moderate increase in cardiac output. Phenylephrine can be used for patients with tachyarrhythmias. A meta-analysis showed increased mortality in patients with septic shock who received dopamine compared to norepinephrine; dopamine is sometimes reserved as a second-line agent in highly selected patients with bradycardia and low risk of tachyarrhythmias. Epinephrine is useful in anaphylaxis or as a second-line agent after norepinephrine. Vasopressin decreases the requirements of the other vasopressors but does not improve mortality in septic shock. (Choice A) Dobutamine is a strong β-agonist and is useful in the management of patients with congestive heart failure who need inotropic support rather than vasoconstriction. Dobutamine would only worsen this patient's poor systemic vascular resistance and could exacerbate the hypotension. (Choice B) Intravenous corticosteroids (hydrocortisone 200-300 mg/day) may be considered in patients who have adrenal insufficiency. Even in the setting of known adrenal insufficiency, rapid institution of norepinephrine or dopamine takes precedence. (Choice D) Compared to a liberal transfusion strategy (hemoglobin <10 g/dL), a restrictive transfusion strategy (hemoglobin <7 g/dL) was associated with decreased hospital mortality. This patient's hemoglobin of 11.9 g/dL is above transfusion thresholds. (Choice E) This patient has hypotension that has persisted despite fluid boluses and is beginning to show signs of volume overload with basilar crackles (suggestive of pulmonary edema) and elevated central venous pressure. Vasopressor therapy is indicated at this stage. Educational objective: Patients in septic shock who do not respond to fluid resuscitation require vasopressors to improve their poor systemic vascular resistance. Norepinephrine is the preferred vasopressor agent for septic shock. __________ References: Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. (http://www.ncbi.nlm.nih.gov/pubmed/18158437) Comparison of equipressor doses of norepinephrine, epinephrine, and phenylephrine on septic myocardial dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/22407285) Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/22036860)

A 55-Year-Old Woman Is Hospitalized for Shortness of Breath, Productive