A 68-year-old woman is brought to the emergency department due to worsening fever, cough, and confusion. The patient has had a "cold and congestion" since last week, which initially improved, but she began feeling worse again 3 days ago. Her daughter reports that the patient has also been eating poorly. Other medical conditions include chronic obstructive pulmonary disease and chronic kidney disease. Temperature is 39.4 C (102.9 F), blood pressure is 74/46 mm Hg, pulse is 128/min, and respirations are 30/min. Oxygen saturation is 94% on 2 L/min. On physical examination, the patient is lethargic with dry mucous membranes and flat neck veins. Lung examination reveals dullness to percussion and crackles at the right base. Chest x-ray shows a right lower lobe consolidation. Intravenous access is established. Intravenous administration of which of the following is the most appropriate next step in management of this patient?

Question

A 68-year-old woman is brought to the emergency department due to worsening fever, cough, and confusion.  The patient has had a "cold and congestion" since last week, which initially improved, but she began feeling worse again 3 days ago.  Her daughter reports that the patient has also been eating poorly.  Other medical conditions include chronic obstructive pulmonary disease and chronic kidney disease.  Temperature is 39.4 C (102.9 F), blood pressure is 74/46 mm Hg, pulse is 128/min, and respirations are 30/min.  Oxygen saturation is 94% on 2 L/min.  On physical examination, the patient is lethargic with dry mucous membranes and flat neck veins.  Lung examination reveals dullness to percussion and crackles at the right base.  Chest x-ray shows a right lower lobe consolidation.  Intravenous access is established.  Intravenous administration of which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec160b_3ceb_a467_9249_15a0b7728437_MD0001_00 This patient with fever, cough, and radiologic evidence of consolidation in the right lower lung has pneumonia. Her tachycardia, hypotension, and confusion (evidence of end-organ hypoperfusion) are most likely due to septic shock, which is characterized by increased permeability of the vascular endothelium with leakage of intravascular fluid into the extravascular space. In the management of septic shock, rapid restoration of intravascular volume and adequate end-organ perfusion is critical. This is best accomplished with the administration of boluses of isotonic crystalloid in the form of 0.9% (normal) saline or lactated Ringer solution through large-bore, peripheral intravenous catheters. These solutions are ideal for volume resuscitation because they have osmolarity very close to the normal osmolarity of the blood (~285 mOsm/kg H₂O), while the sodium and chloride ions help retain the fluid in the extracellular space. Prompt initiation of appropriate empiric antibiotic therapy is also critical in the management of septic shock. (Choices A and C) 0.45% (half-normal) saline is hypotonic; 5% dextrose in 0.45% saline is hypertonic initially but becomes hypotonic following infusion because the dextrose is rapidly metabolized. These hypotonic solutions are often used at low infusion rates for patients with a deficiency of free water (ie, hypernatremia) or for maintenance hydration. However, they are not effective for rapid volume resuscitation because the low osmolarity causes much of the fluid volume to shift into the intracellular space following infusion. (Choice B) Infusion of 3% (hypertonic) saline can lead to rapid fluid-shifting from the intracellular to the extracellular space with potentially devasting consequences (eg, osmotic demyelination syndrome); therefore, 3% saline is not appropriate for rapid volume resuscitation. It is appropriate for careful use in patients with severe symptomatic hyponatremia. (Choice D) Albumin solution is an isotonic colloid solution that can be used for rapid volume resuscitation. However, it is less preferred due to high cost and limited availability compared to isotonic crystalloid. (Choice F) Sodium bicarbonate solutions can have variable tonicity and are typically used at low infusion rates for patients with severe metabolic acidosis. These solutions are generally not used for rapid volume resuscitation. Educational objective: The initial management of septic shock requires rapid fluid resuscitation to replace intravascular volume and restore adequate end-organ perfusion. This is best accomplished with intravenous boluses of isotonic crystalloid in the form of 0.9% (normal) saline or lactated Ringer solution because these solutions remain in the extracellular space.

A 68-Year-Old Woman Is Brought to the Emergency Department Due