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Presentation of Case
A 77-year-old man is admitted to the intensive care unit (ICU) of a university hospital from the operating room. Earlier the same day, he had presented to the emergency department with abdominal pain. His medical history included treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment. In the emergency department, he was drowsy and confused when roused and was peripherally cold with cyanosis. The systemic arterial blood pressure was 75/50 mm Hg, and the heart rate was 125 beats per minute. The abdomen was tense and distended. After the administration of 1 liter of intravenous crystalloid to restore the blood pressure, a computed tomographic scan of the abdomen showed extraluminal gas and suspected extraluminal feces consistent with a perforated sigmoid colon. He was treated with intravenous antibiotics and taken to the operating room for laparotomy. During this procedure, gross fecal peritonitis from a perforated sigmoid colon was confirmed; resection of the sigmoid colon with closure of the rectal stump and creation of an end colostomy (Hartmann’s procedure) was performed with extensive peritoneal toilet and washout.
On arrival in the ICU, he is still anesthetized, the trachea is intubated, and the lungs are mechanically ventilated with a fraction of inspired oxygen of 0.4; the arterial blood pressure is supported with a norepinephrine infusion. When the patient was in the operating room, he received a total of 4 liters of crystalloid. On his arrival in the ICU, the vital signs are a blood pressure of 88/52 mm Hg, heart rate of 120 beats per minute in sinus rhythm, central venous pressure of 6 mm Hg, and temperature of 35.6°C. An analysis of arterial blood shows a pH of 7.32, a partial pressure of carbon dioxide of 28 mm Hg, a partial pressure of oxygen of 85 mm Hg, and a lactate level of 3.0 mmol per liter.
What therapy should be instituted to reduce this patient’s risk of dying from septic shock?