A 66-year-old male with chronic rheumatoid arthritis is brought to the emergency department with fever, cough


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A 66-year-old male with chronic rheumatoid arthritis is brought to the emergency department with fever, cough productive of yellow sputum, and confusion. He has had severe rheumatoid arthritis for the past twelve years. He has been taking methotrexate, prednisone, and non-steroidal anti-inflammatory drugs as needed for the last several years. Physical examination reveals an ill-appearing male with central fat deposition and thin extremities. Joint deformities are consistent with advanced rheumatoid arthritis. His blood pressure is 73/40 mm Hg, heart rate is 123/min, temperature is 102 F (38.9 C) and respirations are 24/min. His oxygen saturation by pulse oximetry is 92% on two liters of nasal canula oxygen. His mucous membranes appear moist. There is no pallor or icterus. Lung examination reveals crackles over the left base. Laboratory investigations reveal a WBC count of 22,000/mm’. His serum sodium is 131 mEq/L and BUN is 27 mg/dl. His blood glucose level is 249 mg/dl. Chest x-ray shows a dense area of left lower lobe consolidation. EKG shows sinus tachycardia with nonspecific ST -T wave changes. A right-sided internal jugular vein catheter is placed and a central venous pressure of 4 mmHg is recorded.
Item 1 of 2
Which of the following immediate measures is most likely to improve this patient’s survival?

  • A. Dobutamine infusion to systolic blood pressure of 90 mmHg [7% 1 .,
  • B. Fluid resuscitation to central venous pressure of 12 mmHg [87%1
  • C. Insulin therapy to blood glucose level of 150 mg/dL [2%1
  • D. Non-invasive positive pressure ventilation [3% 1
  • E. Pulmonary artery catheterization to estimate left ventricular filling [1 %1

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Explanation: User ld:
This patient’s temperature of greater than 38.5 C, heart rate >90 beats/min, respiratory rate >20/min, and WBC >12,000/mm’ meet criteria for the systemic inflammatory response syndrome (SIRS). Only two out of these four criteria are needed to meet the definition of SIRS, although evaluation of this patient’s WBC level is difficult secondary to his prednisone use which may result in an elevated WBC count. The crackles in the left lung base with a confirmed area of consolidation on chest radiograph are likely secondary to pneumonia, strongly suggesting SIRS due to sepsis. The immunosuppressants prednisone and me thotrexate being used This patient’s temperature of greater than 38.5 C, heart rate >90 beats/min, respiratory rate >20/min, and WBC >12,000/mm’ meet criteria for the systemic inflammatory response syndrome (SIRS). Only two out of these four criteria are needed to meet the definition of SIRS, although evaluation of this patient’s WBC level is difficult secondary to his prednisone use which may result in an elevated WBC count. The crackles in the left lung base with a confirmed area of consolidation on chest radiograph are likely secondary to pneumonia, strongly suggesting SIRS due to sepsis. The immunosuppressants prednisone and methotrexate being used to treat this patient’s rheumatoid arthritis probably predisposed him to development of infection. His cushingoid central fat deposition suggests a history of high prednisone use.
The patient’s borderline low blood pressure is concerning for the development of septic shock and placement of a central venous line is appropriate at this time. A serum lactate measurement may be helpful to determine the severity of hypoperfusion. Aggressive fluid management is the first-line treatment in hypoperfusion from sepsis; fluids should be administered until this patient’s central venous pressure is in the 8-12 mmHg range. Vasopressors may be needed if the patient is persistently hypotensive despite aggressive fluid resuscitation.
(Choice A) Vasopressors such as norepinephrine or dopamine are only needed if the patient is persistently hypotensive (MAP of <65) after the central venous pressure has been raised to 8-12 mmHg. Dobutamine has more of an inotropic effect and would only be useful if low cardiac output was suspected.
(Choice C) Glycemic control to maintain a blood glucose of 150 mg/dl has been shown to improve outcomes in patients with septic shock, although this is not as important initially as aggressive fluid resuscitation.
(Choice D) Non-invasive positive pressure ventilation is likely not needed at this time as the patient is only mildly hypoxic and tachypneic. Aggressive fluid resuscitation is the most important first step.
(Choice E) The routine use of pulmonary artery catheters has not been shown to improve outcomes in patients with septic shock.
Educational objective: The most important first step in the management of septic shock is aggressive fluid resuscitation to a central venous pressure of 8-12 mmHg. Vasopressors such as norepinephrine or dopamine should be added if the patient’s hypotension is poorly responsive to fluid resuscitation