Shock Syndromes I

Answer: B

The patient has hypovolemic shock caused by his upper

GI hemorrhage and has symptoms of compromised end-

organ perfusion (i.e., confusion). Although his history

of hypertension is relevant in relation to determining a

resuscitation goal, it does not acutely affect Do2 (Answer

A is incorrect). Tachycardia is a symptom in response to

his hypovolemia, and, in the absence of complicating

factors (e.g., atrial fibrillation or LV diastolic dysfunc-

tion), tachycardia will increase (not decrease) Do2

(Answer C is incorrect). Leukocytosis does not impede

Do2 until it reaches an exorbitant threshold (greater than

75 L/mm3) (Answer D is incorrect). When examining the

Fick equation for Do2, acute anemia is the determinant

that is adversely affecting Do2 (Answer B is correct).

The patient has evidence of vasodilatory shock post-

resuscitation, with his relatively high CVP and PCWP

values and high CO (Answer C is correct). This is further

confirmed by a calculated SVR of 541 dynes x second x

cm-5. The patient could be thought to have spontaneous

bacterial peritonitis in the setting of cirrhosis and asci-

tes complicated by upper GI hemorrhage. Even though

his presentation suggests hypovolemic shock (from GI

hemorrhage), his MAP did not respond to fluid and

blood product administration. Furthermore, he does not

have low preload or low CO (Answer A is incorrect). If

the patient had a low CO together with a high SVR, car-

diogenic shock or obstructive shock might be possible

(with one differentiation depending on CVP/right atrial

pressure and PCWP), but this is untrue for the patient

(Answers B and D are incorrect).

Answer: C

The patient’s clinical scenario of refractory hypoxemia

and hypotension with hypoperfusion suggests that an

accurate prediction of fluid responsiveness is needed.

Dynamic markers of fluid responsiveness (e.g., SVV)

are superior to static markers of fluid responsiveness

(e.g., CVP and PCWP) (Answer C is correct; Answers

A and B are incorrect). A low MAP may be from either

a low CO or a low SVR. Furthermore, a low preload is

only one of many components that may contribute to a

low CO. As such, a low MAP is not a good predictor of

fluid responsiveness (Answer D is incorrect).

Answer: C

The patient has shock with hypoperfusion and a posi-

tive response to a PLR test, which suggests he is still

fluid responsive (Answer D is incorrect). Data from a

large randomized trial of patients with heterogeneous

shock types showed no difference in efficacy and safety

between albumin and 0.9% sodium chloride, but the

cost of albumin is substantially higher. These data sug-

gest that crystalloids such as 0.9% sodium chloride are

preferred for fluid resuscitation in the ICU. In addition,

the patient has not received a substantial volume of

fluid (he has received less than 30 mL/kg; Answer C

is correct; Answer A is incorrect). Hydroxyethyl starch,

which has been associated with an increased need for

renal replacement therapy without a mortality benefit,

should be avoided for fluid resuscitation in the ICU

(Answer B is incorrect).

Answer: D

The patient has evidence of ventricular dysfunction

with a low Scvo2 and poor ventricular contractility on

echocardiogram. A vasoactive agent with strong ino-

tropic properties is indicated. Epinephrine has strong

β1-adrenergic properties and is the best selection in this

case (Answer D is correct). Both phenylephrine and

vasopressin are essentially pure vasoconstrictors that

do not increase CO and could theoretically decrease

CO. In addition, use of phenylephrine is no longer rec-

ommended by the guidelines (Answers A and B are

incorrect). Although norepinephrine has β1-adrenergic

properties, it primarily increases blood pressure

through vasoconstriction secondary to its α1-adrenergic

properties, with only minimal effects on CO. Increasing

norepinephrine in this case would probably not improve

the patient’s CO sufficiently to improve tissue perfusion

(Answer C is incorrect).

Answer: B

The patient has life-threatening organ dysfunction

secondary to infection. Although not all the criteria to

calculate the score are available, her SOFA score is at

least 4 points (2 points for Plt, 1 point for Glasgow Coma

Scale score, and 1 point for SCr), indicating organ dys-

function. In addition, the patient fulfills all three qSOFA

criteria (altered mental status, SBP of 100 mm Hg or less,

and respiratory rate of 22 breaths/minute or greater).

Therefore, she meets the criteria for sepsis, according