101 - 105 SBAs for the Final FRCA
Question 101
A 69 year old man is admitted to intensive care with septic shock secondary to a nasty pneumonia.
In ED he received fluid resuscitation with boluses of balanced crystalloid and has just been started on a noradrenaline infusion.
His numbers look like this:
- MAP 59 mmHg
- Lactate 2.8 mmol/litre
- Capillary refill time 2 seconds, no skin mottling
A passive leg raise produces a 14% increase in stroke volume according to cardiac output monitoring.
Which of the following is the most appropriate next step?
- 500 ml PlasmaLyte
- 500 ml 0.9% saline
- Increase noradrenaline to target a MAP of 65 mmHg
- Give 20% albumin as an intravascular volume expander
- Continue with current management and recheck lactate in an hour
Answer
- Increase noradrenaline to target a MAP of 65 mmHg
This patient is fluid responsive, as demonstrated by the increase in stroke volume when a passive leg raise is performed.
However there is a difference between fluid responsive and needing more fluid, and the former does not necessarily imply the latter.
- The problem in septic shock is usually vasoplegia not hypovolaemia
This patient has adequate peripheral perfusion and a tolerable lactate in the context of septic shock requiring vasopressors.
However the MAP is rather low, and most 69 year old men possess coronary arteries that would prefer a little more perfusion pressure, so ideally we'd bring that up a smidge.