Shock Syndromes I

Patient Case

A 56-year-old woman with a medical history of hypertension presents to the ED with shortness of breath

and cough productive of sputum. Her vital signs on admission are as follows: blood pressure 92/68 mm Hg,

heart rate 104 beats/minute, respiratory rate 26 breaths/minute, and temperature 101.6°F (38.7°C). A chest

radiograph reveals an opacity in the left lower lobe, but the radiograph is otherwise unremarkable. Her labo-

ratory values of interest include Hgb 12.7 g/dL, WBC 16.4 × 103 cells/mm3, Plt 80,000/mm3, albumin 2.0

g/dL, lactate 3.2 mmol/L, and SCr 1.3 mg/dL. Her Glasgow Coma Scale score is 13. Which best describes

the patient’s condition?

Antimicrobials

Timing of initiation

Adequate empiric antibiotics should be initiated within 1 hour after recognizing sepsis or

septic shock.

ii.

A multicenter, retrospective study of patients with septic shock found that within the first 6 hours

after the onset of hypotension, each hour of delay beyond the first hour in the administration of

appropriate antibiotics was associated with a 7.6% decrease in hospital survival.

iii.

Other studies have further shown the importance of empiric antimicrobials used together with

initial resuscitation, associating antimicrobial administration either before shock or within the

initial hour of shock with improved survival.

Initial empiric broad-spectrum therapy should include one or more drugs with activity against all

likely pathogens (bacterial and/or fungal and/or viral).

In an observational study of more than 5700 patients with septic shock, those who received

initial appropriate antimicrobials had a significantly higher hospital survival rate than did

those who received initial inappropriate antimicrobials (52.0% vs. 10.3%, p<0.0001).

ii.

Combination antibacterial therapy (at least two different classes of antibiotics) is indicated for

patients with septic shock, but not for those with sepsis without shock.

allocated patients to meropenem monotherapy or combination therapy with meropenem

and moxifloxacin found no difference between groups in mean SOFA scores over 14

days (7.9 points vs. 8.3 points, p=0.36) or mortality rates at 28 or 90 days. Important

caveats to this study are that the patient population studied was at a low risk of resistant

pathogens (half of the patients had a community-acquired infection) and that moxifloxacin

inadequately covers pathogens with a high likelihood of multidrug resistance (e.g.,

Pseudomonas aeruginosa and Acinetobacter spp.).

detected no overall mortality benefit of combination antibacterial therapy compared

with monotherapy (pooled OR of death 0.86; 95% CI, 0.71–1.03, p=0.09); however, a

stratified analysis showed significantly lower mortality with combination therapy in more

severely ill patients (monotherapy risk of death greater than 25%, pooled OR of death

with combination therapy 0.54; 95% CI, 0.45–0.66, p<0.001). The benefit of combination

therapy was confined to patients with septic shock (with no benefit of combination therapy

in patients without shock). In addition, a meta-regression analysis, which tried to elucidate