New from Critical Care Medicine, Clinicians Corner explores a patient case that has sparked debate. Review the case details, vote on how you would treat the patient, and after you submit, see how current poll results are trending. Then watch for the October issue Critical Care Medicine, which will feature the Clinicians Corner article with an in-depth discussion of the case from three critical care experts.
A 54-year-old woman with diabetes on insulin presents to the emergency department with a 2-day history of cough productive of yellow-green sputum and increasing respiratory distress. On arrival, temperature is 40 °C (104 °F), blood pressure 80/55 mm Hg, heart rate 125 beats/min, respiratory rate 36 breaths/min, and oxygen saturation 85% on 6 L nasal cannula. Chest radiograph shows diffuse bilateral infiltrates, right greater than left. She is administered 2 L crystalloid and started on antibiotics appropriate for community-acquired pneumonia. For increasing shortness of breath, she is trialed on heated high-flow nasal cannula without improvement in her respiratory distress or saturation and is intubated at FIO2 0.7 and positive end-expiratory pressure (PEEP) 8 cm H2O. Arterial blood gas analysis shows pH 7.38, PCO2 41 mm Hg and PaO2 68 mm Hg with tidal volume 6 mL/kg ideal body weight. Peak pressure is 24 cm H2O and plateau pressure is 22 cm H2O.
Which of the following is the most appropriate next step in managing the PEEP and FIO2?
A 52-year-old woman presents to the emergency department with a 1- to 2-day history of fever, right flank pain, and nausea. Vital signs are: temperature 39.1 °C (102.4 °F), heart rate 130 beats/min, respiratory rate 22 breaths/min, and blood pressure 70/40 mm Hg. She has right costovertebral angle tenderness. Laboratory findings are: WBCs 15 × 103/μL, creatinine 1.9 mg/dL, and lactate 3.5 mmol/L. Urinalysis reveals many WBCs and few RBCs. CT reveals right hydronephrosis with an obstructing ureteral stone. She receives 2 L lactated Ringer solution and is started on norepinephrine and broad-spectrum antibiotics. Blood and urine cultures are pending. Urology plans intervention once the patient is stabilized. Despite increasing norepinephrine to 0.25 µg/kg/min, blood pressure remains low at 80/50 mm Hg.
Which of the following is the most appropriate next step?
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Read the research: Clinicians Corner: Practical Tips for Clinical Stabilization in Septic Shock
