A 55-year-old man is brought to the emergency department due to a gunshot wound to the left abdomen. He undergoes an exploratory laparotomy involving a partial small bowel resection and a left nephrectomy. His postoperative hemoglobin is 10.4 mg/dL. The patient has no other medical history and takes no medications. Recovery is uneventful until postoperative day 4 when he develops fever, tachypnea, and shortness of breath. The patient is lethargic but responsive. Temperature is 38.9 C (102 F), blood pressure is 75/50 mm Hg, pulse is 110/min and regular, and respirations are 22/min. There is no jugular venous distention. Lung auscultation reveals crackles at the right lung base. There are no cardiac murmurs. Abdominal examination shows a well-healing abdominal wound and a soft, nondistended abdomen. His urine output over the last 12 hours is 100 mL. Laboratory results are as follows: Broad-spectrum antibiotics are started. Which of the following additional treatments is the most appropriate next step in management of this patient?

Question

A 55-year-old man is brought to the emergency department due to a gunshot wound to the left abdomen.  He undergoes an exploratory laparotomy involving a partial small bowel resection and a left nephrectomy.  His postoperative hemoglobin is 10.4 mg/dL.  The patient has no other medical history and takes no medications.  Recovery is uneventful until postoperative day 4 when he develops fever, tachypnea, and shortness of breath.  The patient is lethargic but responsive.  Temperature is 38.9 C (102 F), blood pressure is 75/50 mm Hg, pulse is 110/min and regular, and respirations are 22/min.  There is no jugular venous distention.  Lung auscultation reveals crackles at the right lung base.  There are no cardiac murmurs.  Abdominal examination shows a well-healing abdominal wound and a soft, nondistended abdomen.  His urine output over the last 12 hours is 100 mL.  Laboratory results are as follows: Broad-spectrum antibiotics are started.  Which of the following additional treatments is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient has likely developed pneumonia and has signs of septic shock, including fever, tachycardia, hypotension, and poor urine output. After securing an airway, if needed, the goals in managing septic shock include restoring adequate tissue perfusion and identifying the underlying infection and treating it appropriately. Crystalloid solution (eg, normal saline, lactated Ringer) is the fluid of choice to restore volume quickly as it is as effective as albumin in terms of survival but is less costly and easier to acquire (Choice C). Crystalloid should be given as intravenous boluses (500-1000 mL) to improve systolic blood pressure >90 mm Hg, at which perfusion is considered adequate. This is continued with close monitoring for evidence of volume overload (eg, pulmonary edema, hypoxia) or until fluid no longer improves the blood pressure. If the patient fails to respond or develops evidence of volume overload without improvement in blood pressure, then vasopressors (eg, norepinephrine) should be started to improve perfusion (Choice D). This patient's arterial blood gas is suggestive of a compensated metabolic acidosis (likely lactic acidosis due to organ hypoperfusion); therefore, it would be reasonable to administer isotonic saline without concern about worsening the acidosis. (Choice A) Despite this patient's poor urine output in the past 12 hours, there is no current indication for hemodialysis as he first should be given a fluid challenge through boluses to see if urine output improves. In addition, this patient has a compensated metabolic acidosis, no major electrolytes abnormalities, no uremia, and no volume overload, which are indications to start urgent hemodialysis. (Choice E) Intravenous hydrocortisone can be used in septic shock but is generally started in patients who do not respond to volume resuscitation and the initiation of vasopressors. (Choice F) This patient has a (partially) compensated metabolic acidosis despite a pH of 7.28. The use of bicarbonate is not clearly indicated unless there is a severe acute acidosis (pH <7.2). (Choice G) Generally, even in patients with septic shock, the goal of transfusion is to keep the hemoglobin >7 g/dL unless they have not responded to crystalloid and vasopressors. This patient has a hemoglobin of 9.6 g/dL and no current clear indication (eg, active bleeding) for a red blood cell transfusion. Educational objective: Patients with septic shock first require aggressive volume resuscitation with intravenous 0.9% saline prior to the initiation of vasopressors to restore adequate tissue perfusion. References: Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. (http://www.ncbi.nlm.nih.gov/pubmed/23353941)

A 55-Year-Old Man Is Brought to the Emergency Department Due