Shock Syndromes I

determined that the patient is still fluid responsive,

you would like to give another fluid bolus. Which

fluid is best for the fluid bolus?

A 48-year-old man (weight 82 kg) presents to the

medical ICU for septic shock secondary to a urinary

tract infection. His medical history is significant only

for hypertension. The patient has an initial mean

arterial pressure (MAP) of 58 mm Hg and a lactate

concentration of 4.8 mmol/L. The patient is initi-

ated on broad-spectrum antimicrobials, has a central

venous catheter placed in his right subclavian vein,

and is resuscitated with quantitative resuscitation. He

receives 2 L of 0.9% sodium chloride total and 2 L

of lactated Ringer’s solution, and he is initiated on

norepinephrine. Three hours after presentation, his

current pertinent vital signs, hemodynamic param-

eters, and laboratory values are as follows: MAP 68

mm Hg on norepinephrine 8 mcg/minute, central

venous pressure (CVP) 10 mm Hg, central venous

oxygen saturation (Scvo2) 72%, urinary output 0.2

mL/kg/hour, and lactate 4.6 mmol/L. Which is the

next best step for the patient’s hemodynamic therapy?

An 82-year-old man is admitted to the surgical

ICU after an exploratory laparotomy and small

bowel resection for a small bowel obstruction that

was complicated by fecal peritonitis and hypoten-

sion. The patient received 2 L of lactated Ringer’s

solution, 500 mL of 5% albumin, and 500 mL of

6% hydroxyethyl starch in the operating room,

but vasopressors were never initiated. He remains

intubated and mechanically ventilated, requiring

a 90% fraction of inspired oxygen (Fio2), with the

following vital signs: heart rate 131 beats/minute in

atrial fibrillation, MAP 62 mm Hg (by arterial blood

pressure catheter), respiratory rate 22 breaths/min-

ute, and temperature 100.8°F (38.2°C). An arterial

blood gas show lactate 5.2 mmol/L. An arterial pulse

pressure waveform analysis monitor shows pulse

pressure variation (PPV) 18%. The patient has a cen-

tral venous catheter in his right femoral vein. Which

next step is best?

A 19-year-old man is admitted to the medical ICU

for hypotension after being stung by a bee. He was

given intramuscular epinephrine by emergency

medical services and transferred to the emergency

department (ED). On arrival at the ED, his blood

pressure was 78/42 mm Hg; he was given 1 L of

0.9% sodium chloride, diphenhydramine, famoti-

dine, and methylprednisolone. The patient remained

hypotensive but responded to an additional 2 L of

0.9% sodium chloride. He was transferred to the

medical ICU for further treatment. On arrival in the

medical ICU, his MAP is 62 mm Hg. A right inter-

nal jugular central venous catheter is placed, which

shows CVP 3 mm Hg, Scvo2 61%, venous lactate

concentration 4.4 mmol/L, and hemoglobin (Hgb)

9.6 g/dL. Together with further fluid resuscitation,

which agent would be best to initiate or administer?

A 56-year-old man (weight 66 kg) presents to the

ED with presumed community-acquired pneumo-

nia. Blood cultures are obtained, and the patient is

given ceftriaxone 1 g and levofloxacin 750 mg. His

initial blood pressure is 83/47 mm Hg with a lactate

concentration of 6.2 mmol/L, and he is given 1.5 L

of 0.9% sodium chloride over 1 hour. Subsequently,

his blood pressure is 92/54 mm Hg with a lactate

concentration of 4.6 mmol/L and urinary output of

30 mL/hour. A central venous catheter placed in his

right internal jugular vein shows a CVP of 6 mm

Hg, and a venous blood gas reading obtained from

the central venous catheter shows an Scvo2 of 63%,

Hgb 9.2 g/dL, and hematocrit (Hct) 28%. Which

would be the best therapy for this patient right now?