What should be done next for an elderly patient with fever, malaise, cough, nausea, vomiting, hypotension, and tachycardia?

Management of Elderly Patient with Suspected Sepsis and Influenza

In an elderly patient presenting with fever, malaise, cough, nausea, vomiting, hypotension, and tachycardia, you should place a central line and start norepinephrine after initial fluid resuscitation has failed to correct hypotension.

Initial Assessment and Management

• The patient presents with classic signs of sepsis: fever (101.5°F), hypotension (BP 85/40), tachycardia (HR 120 bpm), and symptoms including cough, malaise, and vomiting during winter (January), strongly suggesting influenza with possible progression to sepsis 1
• A fluid bolus is already being administered, which is appropriate initial management for hypotension 1
• If hypotension persists after initial fluid resuscitation (which appears to be the case given the patient's current vital signs), vasopressor therapy with norepinephrine should be initiated, requiring central line placement 1

Rationale for Central Line and Vasopressors

• The patient's blood pressure of 85/40 mmHg indicates shock, which requires immediate intervention to prevent organ damage and death 2
• Continuous oxygen therapy is indicated for patients with hypotension with systolic blood pressure < 100 mmHg 2
• For patients with persistent hypotension after fluid resuscitation, vasopressors are necessary to maintain adequate tissue perfusion 1
• The British Infection Society and British Thoracic Society guidelines recommend that all patients with abnormal cardiorespiratory symptoms should have oxygenation assessed and those with hypotension should receive appropriate intervention 2

Infection Control Considerations

• After stabilizing the patient hemodynamically, the patient should be placed in droplet precautions with influenza testing 1
• During influenza season, elderly patients from assisted living facilities are at high risk for influenza complications and secondary bacterial pneumonia 1
• Rapid influenza diagnostic testing can improve patient management and reduce unnecessary antibiotic use 3, 4
• Studies show that influenza point-of-care testing has high sensitivity (94%) and specificity (98%) compared to laboratory-based testing 3

Why Other Options Are Not Appropriate

• Option A (Place the patient in droplet precautions with influenza testing): While this is important, it does not address the immediate life-threatening hypotension which requires vasopressor support 2
• Option B (Order metronidazole 500mg TID): Metronidazole targets anaerobic bacteria and is not appropriate first-line therapy for suspected influenza or community-acquired pneumonia 2
• Option D (Order loperamide 2mg): Loperamide is contraindicated in patients with suspected infectious diarrhea and would not address the patient's primary issues of respiratory symptoms and hemodynamic instability 2

Additional Considerations

• After stabilizing the patient, obtain diagnostic tests including blood cultures, complete blood count, comprehensive metabolic panel, lactate, and chest radiography 1
• Empiric antibiotic therapy should cover community-acquired pneumonia pathogens, as secondary bacterial pneumonia is common in elderly patients with influenza 2
• Elderly patients may present with atypical symptoms of infection, with fever defined as a single oral temperature ≥100°F (37.8°C) 1
• Monitor the patient closely for response to vasopressors and need for additional interventions such as mechanical ventilation if respiratory status deteriorates 2