How to manage a 60-year-old female with T2DM and HTN, presenting with severe sepsis, shock, leukocytosis, elevated procalcitonin, and anuric AKI, unresponsive to initial fluid resuscitation and on noradrenaline?

Management of Septic Shock with Anuric AKI in a 60-Year-Old Female with T2DM and HTN

For a 60-year-old female with T2DM, HTN, presenting with septic shock, leukocytosis, elevated procalcitonin, and anuria who remains hypotensive despite 2L fluid resuscitation and is on noradrenaline, immediate implementation of a comprehensive sepsis protocol with additional vasopressors, early renal replacement therapy, and source control is essential.

Immediate Management Priorities

1. Continue Fluid Resuscitation

• Continue crystalloid fluid resuscitation beyond the initial 2L, targeting at least 30 mL/kg body weight in the first 3 hours 1
• Use balanced crystalloids rather than hydroxyethyl starch solutions which increase risk of AKI 2
• Monitor fluid responsiveness using dynamic parameters (pulse pressure variation, stroke volume variation) 2

2. Optimize Vasopressor Therapy

• Maintain noradrenaline as first-line vasopressor, targeting MAP ≥65 mmHg 2, 1
• Titrate noradrenaline dose gradually from initial 8-12 mcg/min to maintenance 2-4 mcg/min based on hemodynamic response 3
• Consider adding vasopressin (0.03 units/minute) to noradrenaline to improve blood pressure or decrease noradrenaline requirements 2
• For refractory shock, consider adding epinephrine as an additional agent 2

3. Source Control and Antimicrobial Therapy

• Obtain blood cultures immediately (if not already done) 1
• Administer broad-spectrum antibiotics within 1 hour of recognition of sepsis 2, 1
• Identify and control the source of infection (e.g., drain abscesses, debride infected tissues) 2
• Consider the history of loose motions as potential source of infection

4. Renal Replacement Therapy

• Initiate continuous renal replacement therapy (CRRT) promptly for anuric AKI with fluid overload 2
• CRRT is preferred over intermittent hemodialysis in hemodynamically unstable patients 2
• Target fluid removal to prevent >10% total body weight fluid overload 2

Additional Management Considerations

Metabolic Management

• Maintain glucose levels between 110-149 mg/dL (6.1-8.3 mmol/L) using insulin therapy 2
• Provide adequate nutritional support (20-30 kcal/kg/day) 2
• Administer 1.0-1.5 g/kg/day protein for patients on RRT, up to 1.7 g/kg/day for those on CRRT 2

Adjunctive Therapies

• Consider hydrocortisone (200-300 mg/day) if vasopressor requirements remain high despite adequate fluid resuscitation 2, 1
• Provide DVT prophylaxis 1
• Implement lung-protective ventilation strategies if mechanical ventilation is required 1

Monitoring Parameters

• Continuous hemodynamic monitoring (arterial line for accurate BP measurement) 2
• Monitor urine output, serum creatinine, and electrolytes frequently
• Assess tissue perfusion (capillary refill, skin mottling, peripheral pulses) 1
• Consider PiCCO monitoring which has shown benefits in managing septic shock with AKI compared to CVP-guided therapy 4

Pitfalls and Caveats

1. Avoid fluid overload: While initial resuscitation is crucial, excessive fluid administration worsens outcomes in septic AKI 5
2. Don't delay antibiotics: Each hour delay in antibiotic administration increases mortality 1
3. Don't use dopamine for renal protection: Low-dose dopamine does not protect renal function 2
4. Don't delay RRT: Early initiation of RRT may be beneficial in anuric patients with septic shock 6
5. Beware of abrupt withdrawal: When discontinuing noradrenaline, reduce flow rate gradually to avoid rebound hypotension 3

This patient's anuric state despite fluid resuscitation and vasopressor therapy indicates severe AKI requiring prompt intervention. The combination of septic shock, leukocytosis, and elevated procalcitonin (>100) suggests severe infection requiring aggressive management according to current sepsis guidelines.