Internal Medicine · Year 3 · from Internal Medicine

Case 3: Sepsis Resuscitation and Reassessment

Patient Presentation

A 55-year-old man with no significant medical history presents with 2 days of fever, productive cough, and worsening shortness of breath. Chest X-ray shows right lower lobe consolidation. Initial vitals show: BP 95/60, HR 105, RR 24, T 38.9°C, SpO2 92% on room air. Lactate is 3.8 mmol/L. He receives 30 mL/kg crystalloid and ceftriaxone plus azithromycin.

Post-Resuscitation Assessment (2 hours later)

  • Blood Pressure: 102/65 mmHg (MAP 77)
  • Heart Rate: 95 bpm
  • Respiratory Rate: 20/min
  • Oxygen Saturation: 96% on 2L NC
  • Urine output: 60 mL in past hour
  • Repeat lactate: 2.4 mmol/L
  • Mental status: Alert and oriented

Physical Examination Post-Fluids

  • General: Improved, more alert
  • Cardiovascular: Regular rhythm, warm extremities, capillary refill <2 seconds
  • Pulmonary: Crackles at right base, improved work of breathing
  • Extremities: No mottling

Clinical Image

Figure 3: Algorithm for sepsis resuscitation showing dynamic assessment of fluid responsiveness and perfusion markers.

Image Source: Educational illustration for teaching purposes.

Questions

  1. What markers indicate adequate resuscitation in this patient?
  • A) Normal blood pressure only
  • B) Improved MAP, decreasing lactate, adequate urine output, improved mental status, warm extremities
  • C) Absence of fever
  • D) Normal heart rate
  1. What is the role of dynamic measures of fluid responsiveness?
  • A) Replacing clinical assessment
  • B) Guiding further fluid administration to avoid both under- and over-resuscitation
  • C) Determining antibiotic choice
  • D) Predicting mortality
  1. What is the appropriate duration of antibiotic therapy for uncomplicated pneumonia with sepsis?
  • A) 3 days
  • B) 5-7 days
  • C) 14 days
  • D) 21 days
  1. What are the potential harms of excessive fluid resuscitation?
  1. When should corticosteroids be considered in septic shock?

Answers

  1. B) Improved MAP, decreasing lactate, adequate urine output, improved mental status, warm extremities - Multiple markers of perfusion should be assessed:
  • MAP ≥65 mmHg
  • Lactate clearing (this patient: 3.8 → 2.4 mmol/L)
  • Urine output ≥0.5 mL/kg/hr
  • Mental status improvement
  • Normalization of skin perfusion (warm, not mottled)
  1. B) Guiding further fluid administration to avoid both under- and over-resuscitation - Dynamic measures include:
  • Passive leg raise response
  • Pulse pressure variation (mechanically ventilated)
  • Stroke volume variation
  • IVC collapsibility (limited accuracy)
  • These help determine if patient will benefit from additional fluids vs. moving to vasopressors
  1. B) 5-7 days - For most pneumonia with sepsis, 5-7 days is sufficient if clinical improvement occurs. Procalcitonin can guide discontinuation. Longer courses may be needed for:
  • Pseudomonas or MRSA
  • Lung abscess or empyema
  • Immunocompromised patients
  1. Harms of excessive fluid resuscitation:
  • Pulmonary edema and worsening respiratory failure
  • Peripheral edema and impaired wound healing
  • Intra-abdominal hypertension/abdominal compartment syndrome
  • Dilutional coagulopathy
  • Increased mortality in some studies (FEAST trial, CLOVERS trial suggests equipoise)
  • Need for prolonged mechanical ventilation
  • Goal is "just enough" fluid to optimize perfusion
  1. Corticosteroid indications in septic shock:
  • Consider if vasopressor requirements are escalating or persistently high
  • Typically hydrocortisone 200 mg/day (50 mg IV q6h or 200 mg continuous infusion)
  • Survival benefit in refractory shock (APROCCHSS trial)
  • May speed shock reversal (ADRENAL trial)
  • Do not routinely test cortisol levels
  • Discontinue once vasopressors weaned

Learning Points

  1. Sepsis-3 definition requires infection plus organ dysfunction (SOFA score increase ≥2); septic shock adds hypotension requiring vasopressors and lactate >2 despite fluids.
  1. Hour-1 Bundle includes lactate measurement, blood cultures, antibiotics, and fluid resuscitation initiated within 1 hour.
  1. Norepinephrine is the first-line vasopressor for septic shock; target MAP ≥65 mmHg.
  1. Source control (e.g., drainage of abscess, removal of infected catheter, biliary decompression) is essential and should not be delayed.
  1. Reassessment of perfusion markers guides ongoing resuscitation; both under-resuscitation and over-resuscitation can cause harm.

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