A 58-year-old man is evaluated in the hospital for fever, hypotension, and altered mental status. He was hospitalized 2 days ago for an infected arm wound and was treated with intravenous piperacillin/tazobactam and vancomycin. This morning he developed new pain in the middle of his back and difficulty urinating. His medical history is significant for type 2 diabetes mellitus treated with metformin.
On physical examination, temperature is 39.1 °C (102.4 °F), blood pressure is 83/48 mm Hg, pulse rate is 109/min, and respiration rate is 21/min. Oxygen saturation is 98% breathing 2 L/min of oxygen through nasal cannula. He is somnolent but arousable and oriented when awake. There is erythema surrounding the wound on his right upper arm with no drainage or tenderness. There is tenderness to percussion in the middle of his back and a palpable bladder.
Laboratory studies reveal a blood serum leukocyte count of 22,000/µL (22 × 109/L), and plasma glucose of 160 mg/dL (8.88 mmol/L).
Chest radiograph is unremarkable.
Which of the following is the most appropriate next step in management?
A. Intravenous fluid bolus
B. Intravenous insulin
C. MRI of the spine
D. Surgical exploration of the arm wound
MKSAP Answer and Critique
The correct answer is A. Intravenous fluid bolus. This item is available to MKSAP 18 subscribers as item 55 in Pulmonary and Critical Care Medicine section. More information about MKSAP 18 is available online.
The most appropriate management is an intravenous fluid bolus of 30 mL/kg of body weight. Successful treatment of severe sepsis and septic shock depends on the rapid institution of hemodynamic support, empiric treatment of infection, and infection control. Crystalloid infusion (normal [0.9%] saline or lactated Ringer solution) to support circulating intravascular volume should be administered to all patients with severe sepsis and septic shock. The 2016 update to the Surviving Sepsis Guidelines recommends using an initial bolus of 30 mL/kg of body weight.
The 2018 American Diabetes Association Standards for Care recommend that insulin therapy be initiated for treatment of persistent hyperglycemia starting at a threshold of 180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140 to 180 mg/dL (7.8–10.0 mmol/L) is recommended for most critically ill and noncritically ill patients. This patient's plasma glucose is not so high that it is an emergency; therefore, administration of insulin is a lower priority than treatment of shock.
This patient may have also have developed a paraspinous abscess (fever, new-onset back pain, difficulty urinating). This patient may need spine imaging but the more urgent priority is his hemodynamic instability, which requires fluid resuscitation before he can undergo any diagnostic imaging study.
Before this patient can be evaluated for surgical source control, he needs to be resuscitated. He is not showing signs of necrotizing fasciitis, which would be a surgical emergency, but even if he were suspected of this diagnosis, he would need aggressive fluid resuscitation while arrangements were made for urgent surgical debridement.
- Patients with hypoperfusion due to sepsis should be managed with aggressive crystalloid fluid resuscitation using an initial bolus of 30 mL/kg of body weight.