A 65-year-old man is admitted to the intensive care unit for septic shock. He is intubated, on mechanical ventilation, and receiving a continuous norepinephrine infusion via a central line. He has developed acute kidney injury (AKI) with anuria, and continuous renal replacement therapy (CRRT) is being prepared. His recent arterial blood gas shows pH 7.08, PaCO₂ 35 mmHg, and HCO₃⁻ 10 mEq/L. His weight is 70 kg. Other labs include Na⁺ 140 mEq/L, K⁺ 4.2 mEq/L, Cl⁻ 105 mEq/L, and ionized Ca²⁺ 1.1 mmol/L. Given the patient’s current acid–base status and clinical context, which of the following is the most appropriate initial pharmacologic intervention?

A 65-year-old male with hypertension and type 2 diabetes is admitted to the ICU for septic shock secondary to pneumonia. He received 30 mL/kg of balanced crystalloid, and current hemodynamic monitoring shows a central venous pressure of 12 mmHg with stroke volume variation of 10%, suggesting adequate fluid resuscitation. He remains hypotensive on norepinephrine 0.1 mcg/kg/min for 2 hours (BP 85/50 mmHg, HR 115 bpm) and is intubated on assist-control ventilation. Urine output is <0.3 mL/kg/hr. Laboratory studies reveal pH 7.05, PaCO2 35 mmHg, HCO3– 12 mEq/L, lactate 6.8 mmol/L, and creatinine 2.5 mg/dL (baseline 0.9 mg/dL). Which of the following pharmacologic interventions is most appropriate to correct his acid-base disturbance?

A 68-year-old male, weighing 70 kg, is admitted to the critical care unit for septic shock requiring mechanical ventilation and norepinephrine infusion via a central venous catheter. He has a history of type 2 diabetes, hypertension, and chronic kidney disease (baseline creatinine 1.8 mg/dL). His current arterial blood gas (ABG) results are pH 7.08, PaCO2 30 mmHg, and HCO3 10 mEq/L. Other pertinent labs include lactate 8.5 mmol/L, creatinine 3.2 mg/dL, potassium 4.0 mEq/L, and sodium 138 mEq/L. Urine output has been <0.5 mL/kg/hr for the past 6 hours despite initial fluid resuscitation. Considering the patient's current acid-base status and comorbidities, which of the following is the MOST appropriate initial pharmacologic intervention to address his acidemia?

A 65-year-old man with end-stage renal disease on maintenance hemodialysis (last session 2 days ago) is admitted to the intensive care unit for septic shock. He is mechanically ventilated with a tidal volume of 6 mL/kg, respiratory rate of 20 breaths/min, and minute ventilation of 7 L/min, and is receiving a continuous norepinephrine infusion via a central venous catheter. An arterial blood gas shows pH 7.05, PaCO2 30 mmHg, and HCO3– 8 mEq/L, with a serum lactate of 10 mmol/L. Which of the following is the most appropriate consideration for managing his acidemia?

“A 65-year-old man (weight 80 kg) with a history of heart failure with preserved ejection fraction is in the ICU for septic shock. He is mechanically ventilated (assist–control mode) for acute hypoxemic respiratory failure and is receiving a continuous norepinephrine infusion at 0.1 mcg/kg/min via a central line. His vital signs are: temperature 38.5 °C, heart rate 110 beats/min, blood pressure 85/55 mm Hg (MAP 65 mm Hg) on vasopressors; central venous pressure is 6 mm Hg. Dynamic assessment shows a pulse pressure variation of 15% and a positive passive leg–raise test with a 12% increase in stroke volume, indicating fluid responsiveness. Nursing reports urine output of 0.2 mL/kg/hr over the past 6 hours.

Laboratory results:
• Arterial blood gas: pH 7.18, PaCO₂ 35 mm Hg, HCO₃⁻ 12 mEq/L
• Chemistry: Na 138 mEq/L, Cl 105 mEq/L, BUN 45 mg/dL, Cr 2.1 mg/dL (baseline 1.0)
• Lactate: 6.8 mmol/L

Considering his hemodynamic status, fluid responsiveness, and severe lactic metabolic acidosis, which of the following is the MOST appropriate initial fluid management strategy?”

A 65-year-old man (70 kg) is admitted to the intensive care unit with septic shock. He requires mechanical ventilation on assist-control mode and a continuous norepinephrine infusion via a central line. An initial arterial blood gas shows: pH 7.08, PaCO2 35 mmHg, PaO2 90 mmHg, and HCO3– 10 mEq/L. His serum lactate is 8.2 mmol/L, and his creatinine has increased from a baseline of 0.9 mg/dL to 2.7 mg/dL. Given these findings, which initial pharmacologic intervention is most appropriate for managing this patient’s acidemia?

A 65-year-old man (70 kg) is admitted to the ICU with septic shock secondary to pneumonia. He is intubated and mechanically ventilated and receiving norepinephrine to maintain a mean arterial pressure of 65 mm Hg. His central venous pressure is 12 mm Hg, and his net fluid balance over the past 24 hours is +1.5 L. Over the last 8 hours, urine output has been 0.3 mL/kg/hr, and serum creatinine has risen from 1.1 to 2.5 mg/dL. Laboratory tests show: Na 138 mEq/L, K 5.2 mEq/L, Cl 103 mEq/L, HCO₃⁻ 12 mEq/L, lactate 6.5 mmol/L. Arterial blood gas reveals pH 7.10 and PaCO₂ 30 mm Hg. Which of the following is the most appropriate next intervention?

A 65-year-old man (70 kg) with septic shock secondary to pneumonia is admitted to the ICU. He is intubated and mechanically ventilated (tidal volume 6 mL/kg, RR 16 breaths/min), and receiving norepinephrine at 0.15 µg/kg/min to maintain a MAP of 65 mmHg. He has received 3 L of balanced crystalloid, and his CVP is 12 mmHg. His urine output has been <0.3 mL/kg/hr for the past 8 hours, and his serum creatinine has risen to 2.5 mg/dL (baseline 1.1 mg/dL). An arterial blood gas shows pH 7.10, PaCO2 35 mmHg, HCO3– 10 mEq/L, and lactate 8.0 mmol/L. Which intervention is most appropriate to directly correct his severe metabolic acidemia?

“A 58-year-old, 70 kg man with septic shock secondary to community-acquired pneumonia has been in the ICU for 10 hours. He received 2 L of balanced crystalloid and is on norepinephrine 0.2 mcg/kg/min to maintain a MAP of 65 mmHg. He is intubated and ventilated on assist-control mode. Over the past 6 hours, his urine output has been 15 mL/hr. Current laboratory results:

pH: 7.05 PaCO2: 35 mmHg HCO3–: 8 mEq/L Lactate: 6.2 mmol/L SCr: 2.8 mg/dL (baseline 1.1 mg/dL)

Considering his severe high-anion gap metabolic acidosis (lactic acidosis with acute kidney injury) and evidence from critical care RCTs, which of the following is the most appropriate initial pharmacologic intervention?”

A 68-year-old man is admitted to the ICU for septic shock. He is on assist-control ventilation and receiving norepinephrine at 0.1 mcg/kg/min to maintain a mean arterial pressure of 65 mmHg. He has a history of congestive heart failure and chronic kidney disease stage IV (baseline serum creatinine 1.8 mg/dL). Over the past 6 hours, he has received 2 L of balanced crystalloid with a net positive fluid balance of 500 mL and is now oliguric. Laboratory results: sodium 138 mEq/L, potassium 4.5 mEq/L, chloride 102 mEq/L, serum creatinine 3.5 mg/dL. Arterial blood gas: pH 7.05, PaCO2 35 mmHg, PaO2 85 mmHg, HCO3– 10 mEq/L. Which of the following is the most appropriate intervention at this time?