A 67-year-old man is 12 hours post emergency Hartmann's procedure for perforated diverticulitis. Despite 3.5 litres of balanced crystalloid, he remains hypotensive: heart rate 118/min, BP 82/48 mmHg (MAP 59 mmHg), lactate 4.2 mmol/L, warm peripheries, urine output 10 mL/hour. He is transferred to critical care. What is the most appropriate next step in his haemodynamic management?
- ACommence noradrenaline via central access, titrated to a mean arterial pressure of at least 65 mmHg, reassessing fluid responsiveness
- BFurther large-volume balanced crystalloid boluses, repeated as often as needed until both the blood pressure and the lactate normalise
- CCommence dobutamine as the first-line agent
- DStart intravenous furosemide to improve urine output
- EGive a unit of packed red cells
Show answer and explanation
Correct answer: A
This is septic shock: hypotension requiring escalation despite adequate initial fluid resuscitation (around 30 mL/kg has been given), with hypoperfusion evidenced by lactate above 2 and oliguria, and the warm peripheries of vasodilatory circulation. Surviving Sepsis guidance is explicit: when hypotension persists after initial fluid resuscitation, vasopressors are started promptly — noradrenaline is the first-line agent — targeting a mean arterial pressure of 65 mmHg, because prolonged hypotension while further fluid is trialled costs organs. Noradrenaline's predominantly alpha-mediated vasoconstriction corrects the pathological vasodilatation at the heart of septic shock; further fluid is then given only where dynamic assessment suggests responsiveness. Vasopressin is the usual second agent, and hydrocortisone is added for escalating requirements.
Why the others are wrong: B — pushing fluid into a vasodilated, leaky circulation past the point of responsiveness causes tissue and pulmonary oedema, worse organ dysfunction and higher mortality; fluid is not a substitute for vasoconstriction. C — dobutamine is an inodilator for low-output states with myocardial dysfunction; given to a warm, vasodilated patient it worsens the hypotension. D — the oliguria is hypoperfusion; diuresing an under-pressured kidney compounds the injury. E — there is no haemorrhage or transfusion trigger presented; blood does not correct vasoplegia.
Key point: Septic shock persisting after initial fluid resuscitation is treated with noradrenaline titrated to a MAP of 65 mmHg — vasopressors are started early rather than pursuing escalating fluid boluses in a vasodilated circulation.
Guidelines: Surviving Sepsis Campaign 2021: septic shock persisting after 30 mL/kg crystalloid needs noradrenaline as first-line vasopressor titrated to a MAP of 65 mmHg, started early and ideally via central access without delaying for it.