Critical Care · Year 4 · from Critical Care
Case 1: Septic Shock with Multi-Organ Dysfunction
Clinical Image
Source: Wikimedia Commons - Central Venous Catheter - CC BY-SA 4.0
Case Presentation
A 68-year-old woman with a history of type 2 diabetes mellitus and hypertension is brought to the emergency department by her family with confusion, fever, and decreased urine output for the past 24 hours. She had been complaining of dysuria and flank pain for 3 days prior to presentation. On examination, vital signs show temperature 39.2C (102.6F), heart rate 118 bpm, respiratory rate 26/min, blood pressure 82/54 mmHg, and oxygen saturation 91% on room air. She is obtunded and oriented only to person. Physical examination reveals dry mucous membranes, warm and flushed skin with mottled lower extremities, and right costovertebral angle tenderness. Initial laboratory studies show WBC 22,000/microL with 15% bands, serum creatinine 2.8 mg/dL (baseline 1.1), lactate 5.2 mmol/L, and platelet count 95,000/microL. Urinalysis reveals pyuria with gram-negative rods on Gram stain. She is diagnosed with septic shock secondary to pyelonephritis complicated by acute kidney injury and thrombocytopenia. A rapid response is called, and she is transferred to the MICU where an arterial line and central venous catheter are placed for hemodynamic monitoring. The sepsis bundle is initiated with blood cultures drawn, broad-spectrum antibiotics (piperacillin-tazobactam and vancomycin) administered within 30 minutes, and 30 mL/kg crystalloid bolus given. Despite 3 liters of IV fluids, her MAP remains 58 mmHg, prompting initiation of norepinephrine at 0.1 mcg/kg/min, titrated to achieve MAP greater than 65 mmHg.
Key Learning Points
- Septic shock is defined by the Sepsis-3 criteria as sepsis with persistent hypotension requiring vasopressors to maintain MAP of 65 mmHg or greater and serum lactate greater than 2 mmol/L despite adequate fluid resuscitation
- The sepsis bundle includes measuring lactate, obtaining blood cultures before antibiotics, administering broad-spectrum antibiotics within 1 hour, and providing 30 mL/kg crystalloid for hypotension or lactate of 4 mmol/L or greater
- Hemodynamic monitoring in the ICU includes arterial lines for continuous blood pressure measurement and central venous catheters for vasopressor administration and CVP monitoring
- Multi-organ dysfunction (renal failure, thrombocytopenia, encephalopathy) indicates severe sepsis and worsens prognosis