Shock Syndromes I

to the new definition (Answer B is correct). Although

she has an elevated lactate concentration, she does not

require vasopressors to maintain a MAP above 65 mm

Hg and therefore does not meet the criteria for septic

shock (Answer C is incorrect). In the new sepsis defini-

tion, severe sepsis and systemic inflammatory response

syndrome are no longer clinical entities in the spectrum

of sepsis severity and should not be used (Answers A

and D are incorrect).

Answer: A

The patient currently has a MAP less than 65 mm Hg

and signs of a global lack of perfusion with an increased

lactate concentration. Vasopressor therapy is indicated

to sustain perfusion. This patient has underlying severe

congestive heart failure with an ejection fraction of 20%;

however, the Scvo2 shows that the patient’s Do2 is suffi-

cient, which suggests he is in distributive septic shock as

opposed to cardiogenic shock. The SSC guidelines rec-

ommend initiating vasopressor therapy to target a MAP

of 65 mm Hg and norepinephrine as the first-choice

vasopressor (Answer A is correct). Vasopressin is cur-

rently recommended only as a secondary vasopressor,

as an addition to catecholamine therapy (Answer B is

incorrect). In septic shock, dobutamine is recommended

only when the Scvo2 is less than 70% and the patient has

an adequate Hgb concentration (Answer C is incorrect).

Epinephrine is currently recommended as an alternative

to norepinephrine. In a study that compared epinephrine

with norepinephrine plus dobutamine, the two arms did

not differ in mortality outcomes; however, epinephrine

was associated with lower pH values and higher lactate

concentrations on day 1 (Answer D is incorrect).

Answer: D

According to the SSC guidelines, corticosteroids may

be considered if patients have a poor response to fluid

resuscitation and vasopressor therapy. In addition,

suggest corticosteroids only in patients requiring mod-

erate- to high-dose vasopressors. In this case, the patient

is receiving relatively low doses of vasopressors with

an adequate MAP; hence, no steroids are currently

necessary (Answer D is correct; Answers A and B are

incorrect). Hydrocortisone is recommended at a dose

of 200–400 mg/day. Administering it as a continuous

infusion could be considered because this might lead to

fewer variations in serum glucose. The ACTH stimula-

tion test to determine which patients with sepsis should

receive hydrocortisone is no longer recommended

because the CORTICUS study showed that the ACTH

stimulation test did not predict response to hydrocorti-

sone therapy (Answer C is incorrect).