Shock Syndromes I

A 68-year-old woman (weight 88 kg) presents to the

ED with a urinary tract infection. Her medical his-

tory is significant for paroxysmal atrial fibrillation.

The patient’s vital signs in the ED are as follows:

blood pressure 83/47 mm Hg, heart rate 118 beats/

minute in atrial fibrillation, respiratory rate 24

breaths/minute, and temperature 102°F (38.9°C).

Her laboratory values of interest in the ED include

white blood cell count (WBC) 19.6 × 103 cells/mm3,

Hgb 9.3 g/dL, albumin 2.4 g/dL, lactate 4.9 mmol/L,

and SCr 1.2 mg/dL. Blood and urinary cultures are

obtained, and she receives levofloxacin 750 mg and

3 L of 0.9% sodium chloride. Thirty minutes after

completing the 0.9% sodium chloride infusion, her

blood pressure is 92/49 mm Hg with a lactate con-

centration of 4.6 mmol/L and urinary output of 30

mL/hour. Which would be the best therapy for this

patient right now?

A 34-year-old man is admitted to the surgical

ICU with septic shock associated with necrotizing

soft tissue infection of the right leg. He received

100% oxygen by high-flow mask; adequate broad-

spectrum antibiotics with vancomycin, piperacillin/

tazobactam, and clindamycin; and quantitative

resuscitation. The patient has been resuscitated

for the past 4 hours with 5 L of normal saline

and currently is hemodynamically unstable on

norepinephrine 14 mcg/minute with a corresponding

blood pressure of 92/45 mm Hg and heart rate of 132

beats/minute in sinus rhythm. His CVP is 12 mm

Hg, Scvo2 72%, urinary output 0.3 mL/kg/hour, and

lactate 7.4 mmol/L. Which would be best to initiate

for this patient?