BCCCP: Sepsis and Septic Shock

A 62-year-old man is in the intensive care unit, mechanically ventilated, and receiving a continuous norepinephrine infusion at 0.1 mcg/kg/min via a central venous catheter to maintain a mean arterial pressure above 65 mm Hg. He was transferred from the emergency department with a suspected urinary tract infection and rapidly deteriorating mental status. His current vital signs are: BP 88/52 mm Hg (MAP 64 mm Hg), HR 118 bpm, RR 28 breaths/min (ventilator-delivered), and T 38.9 °C. Laboratory studies show WBC 22,000/mm³, serum lactate 4.8 mmol/L, and creatinine 2.1 mg/dL (baseline 0.9 mg/dL). His SOFA score is 11. Despite receiving 30 mL/kg of intravenous crystalloid fluids, his hypotension persists. Which of the following best describes the primary pathophysiological mechanism contributing to this patient’s clinical state?

A 62-year-old man is in the ICU on mechanical ventilation for acute respiratory failure and septic shock. He is receiving a norepinephrine infusion at 0.1 mcg/kg/min via a central line. Initial resuscitation included 30 mL/kg crystalloid, and his lactate improved from 6.2 to 4.5 mmol/L with a maintained MAP of 68 mmHg. Over 24 hours, his creatinine rose from 0.9 to 2.8 mg/dL, and urine output dropped to <0.3 mL/kg/hr. He has a cumulative +6 L fluid balance, CVP is 12 mmHg, pulmonary ultrasound shows bilateral B-lines, and a passive leg-raise maneuver fails to increase stroke volume. His potassium is 5.8 mEq/L. ECG shows normal sinus rhythm without peaked T waves. Which is the most appropriate next step?

Which of the following hospital-wide quality improvement initiatives is most strongly associated with reduced mortality in patients with sepsis?

A 68-year-old ICU patient with septic shock is receiving norepinephrine via a triple-lumen right internal jugular central venous catheter. A 20-gauge peripheral IV in the left forearm is also available. The patient requires the initial empiric dose of meropenem to be administered as a 30-minute infusion. Which of the following is the most appropriate route for administration?

A 65-year-old man (weight 75 kg) is admitted to the ICU with severe community-acquired pneumonia. He is on assist-control mechanical ventilation and has a central venous catheter. He has received 30 mL/kg of crystalloids, and his central venous pressure is 12 mm Hg. Dynamic assessment shows a pulse pressure variation of 8% and a negative passive leg-raising test, indicating no further fluid responsiveness. Despite norepinephrine at 0.2 mcg/kg/min, his mean arterial pressure (MAP) remains 58 mm Hg, lactate is 4.5 mmol/L, and cardiac index is 2.0 L/min/m2. The target MAP is ≥65 mm Hg. What is the most appropriate next step in managing his hemodynamic instability?

A 65-year-old man is admitted to the intensive care unit and is receiving mechanical ventilation. A central venous catheter is in place for a vasopressor infusion. He was transferred from a nursing home due to altered mental status and fever. Vital signs are: blood pressure 70/40 mm Hg (MAP 50 mm Hg) despite a 30 mL/kg IV fluid bolus, heart rate 115 bpm, respiratory rate 28 breaths/min (ventilator-controlled), and temperature 39.5 °C. Laboratory results include: WBC 22,000/mm³ with 90% neutrophils, lactate 4.8 mmol/L, creatinine 2.1 mg/dL (baseline 0.9 mg/dL), and bilirubin 2.5 mg/dL. A urinary catheter is in place, and the urine appears cloudy. Based on the clinical presentation, which of the following is the most precise classification of this patient’s condition?

A 65-year-old man, 3 days after surgery for a perforated diverticulum, becomes hypotensive and lethargic. Despite receiving 30 mL/kg of intravenous crystalloids, his mean arterial pressure (MAP) remains 58 mmHg, requiring a norepinephrine infusion of 0.05 mcg/kg/min to maintain MAP ≥65 mmHg. His temperature is 38.9 °C, heart rate 118 bpm, respiratory rate 28 bpm, white blood cell count 18,500/mm³, serum lactate 4.8 mmol/L, creatinine 2.1 mg/dL (baseline 0.9), total bilirubin 3.5 mg/dL, and urine output <0.3 mL/kg/hr. Which of the following findings, when taken together, is most indicative of progression to septic shock?

A 68-year-old man was admitted for severe septic shock that required mechanical ventilation for 10 days and continuous vasopressor support. He is now extubated and off vasopressors. During evening rounds, the patient is disoriented to time and place, frequently attempts to pull at his peripheral IV, and has difficulty following simple commands. His Richmond Agitation-Sedation Scale (RASS) score fluctuates between –1 and +1, and he has a positive Confusion Assessment Method for the ICU (CAM-ICU) indicating delirium. Plans are underway to transfer him out of the ICU in the next 24–48 hours. Which of the following interventions is most critical to prioritize to mitigate post–intensive care syndrome (PICS) and facilitate a safe transition of care?

A 62-year-old man is admitted to the critical care unit, currently on mechanical ventilation for acute respiratory failure, requiring a continuous norepinephrine infusion via a central venous catheter to maintain a mean arterial pressure above 65 mm Hg. He presented with altered mental status, fever (102.5 °F), and a white blood cell count of 22,000/mm³. His serum lactate is 4.8 mmol/L. Review of his medical history reveals poorly controlled type 2 diabetes and a chronic non-healing foot ulcer that he reports “got much worse over the last week.” He lives in a rural area, relies on public transportation, and recently lost his job, leading to a lapse in his health insurance and inability to afford his insulin and wound care supplies. Considering the patient’s presentation and history, which of the following social determinants of health MOST significantly contributed to the progression of his condition to septic shock?

A 62-year-old, 70-kg patient is in the intensive care unit with pneumonia requiring a central venous norepinephrine infusion. Despite receiving 4.5 L (≈64 mL/kg) of crystalloids over the past 24 hours, the patient remains hypotensive. Current vital signs: BP 88/52 mm Hg (MAP 64 mm Hg), HR 118 bpm, RR 28 breaths/min, Temp 39.2 °C. Labs: WBC 18.5 × 10³/mm³, serum creatinine 2.1 mg/dL (baseline 0.9 mg/dL), serum lactate 3.8 mmol/L. Which finding provides the most specific criteria for a diagnosis of septic shock?