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Self-Assessment Questions

Critical Care Medicine

Severe Sepsis/Septic Shock: Review Questions

Todd W. Rice, MD, MSc

Dr. Rice is an assistant professor of medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN.

Choose the single best answer for each question.

Table. Notable Results of Laboratory Testing in the Patient Described in Questions 1 and 2
Click to Enlarge Table

Questions 1 and 2 refer to the following case.

A 65-year-old man with a history of chronic obstructive pulmonary disease, hypertension, and left-sided hemiparesis secondary to a hemorrhagic cerebrovascular accident (CVA) 2 months ago presents to the emergency department (ED) complaining of 3 days of fevers to 102°F, cough producing green sputum with some blood streaks, and pleuritic chest pain. The morning of admission, he became lightheaded and dizzy and had a presyncopal episode. The patient’s temperature is 101.3°F, heart rate is 125 bpm, blood pressure is 80/30 mm Hg, and respiratory rate is 32 breaths/min. He is slightly lethargic but oriented to person, place, and time. Pupils are equal, round, and reactive to light and extraocular movements are intact. There is no jugular venous distention, with 2+ carotid pulses without bruits bilaterally. Lung examination is remarkable for diffuse crackles in all lung fields with some expiratory wheezing. Cardiac examination reveals a regular rate and rhythm, normal S1 and S2, 2/6 systolic ejection murmur at the right upper sternal border radiating into his carotids, and an S4 gallop. No pericardial rubs are appreciated. The abdomen is soft, nontender, and nondistended with normoactive bowel sounds and no hepatosplenomegaly. Extremities are warm without cyanosis or edema. The patient has 1+ femoral pulses and weak posterior tibial pulses bilaterally. He has 3/5 strength in his left upper and lower extremities and 5/5 strength in his right upper and lower extremities, which is his reported baseline. Results of laboratory testing are shown in the Table. On 100% nonrebreather mask, blood gas analysis reveals an arterial pH of 7.20, PaCo2 of 40 mm Hg, and Pao2 of 53 mm Hg. Chest radiograph demonstrates diffuse bilateral infiltrates and normal heart size consistent with acute lung injury. The patient is intubated and a right internal jugular central venous line is placed. His central venous pressure (CVP) is 6 cm H2O, prompting volume resuscitation with 3000 mL of 0.9% NaCl and 2000 mL lactated Ringer’s solution, which increases his CVP to 12 cm H2O. The patient’s blood pressure remains low and he is started on a norepinephrine infusion, which is titrated to 12 µg/min to maintain a mean arterial pressure (MAP) greater than 65 mm Hg. A lumbar puncture is performed and evaluation of cerebrospinal fluid reveals 0 white blood cells, 2 red blood cells (RBCs), a protein level of 55 mg/dL, and a glucose level of 117 mg/dL. Urine output has totaled 20 mL over the last 2 hours. Gram stain of his sputum demonstrates gram-positive cocci in pairs and chains. The patient is admitted to the medical intensive care unit with the diagnosis of septic shock from pneumococcal pneumonia.

1. Which of the following treatments has been shown in a large randomized, multicenter trial to reduce mortality in patients with septic shock?

  1. Drotrecogin alfa (activated)
  2. High-intensity renal replacement therapy (RRT)
  3. Intravenous (IV) hydrocortisone
  4. IV immunoglobulin (IVIG)
  5. IV pentastarch
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2. Which of the following represents an absolute contraindication to the use of the aforementioned treatment in this patient?

  1. International normalized ratio (INR) of 1.9
  2. Platelet count of 75,000 cells/µL
  3. Previous hemorrhagic CVA
  4. Recent lumbar puncture
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Questions 3 and 4 refer to the following case.

A 51-year-old woman with a history of IV heroin use presents to the ED complaining of shortness of breath, chest pain, and lightheadedness on standing. Her temperature is 101.7°F, blood pressure is 75/30 mm Hg, heart rate is 115 bpm, and respiratory rate is 24 breaths/min. She is placed on 4 L of oxygen via nasal cannula with a saturation of 97% and is given 4500 mL of 0.9% NaCl IV fluids, which increases her CVP from 5 to 10 cm H2O. She is started on a continuous infusion of norepinephrine, which is increased to 9 µg/min to maintain MAP above 65 mm Hg. A continuous infusion of vasopressin is initiated at 0.03 U/min to improve her blood pressure. Blood cultures show gram-positive cocci in clusters. She is started on vancomycin, levofloxacin, and piperacillin/tazobactam and admitted to the medical intensive care unit for further management of septic shock.

3. All of the following are components of early goal-directed therapy (EGDT) in the resuscitation of this patient with severe sepsis/septic shock EXCEPT

  1. IV fluid resuscitation targeting CVP 8 to 12 cm H2O
  2. IV vasodilator infusion to maintain MAP < 90 mm Hg
  3. IV vasopressor infusion to maintain MAP > 65 mm Hg
  4. Transfusion of packed RBCs to achieve hematocrit > 35% if venous oxygen saturation (Svo2) < 70%
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4. Which of the following is true of vasopressin in septic shock?

  1. Continuous infusion at low doses improves 28-day overall mortality
  2. Continuous infusion at low doses improves mortality in patients with severe septic shock
  3. Continuous infusion at low doses increases cardiac output
  4. Continuous infusion at low doses reduces the catecholamine infusion requirement
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