What is the first priority for a patient with fever, malaise, cough, nausea, vomiting, hypotension, and tachycardia, suspected of having septic shock?

Immediate Vasopressor Support for Septic Shock

The AGACNP should immediately place a central line and order norepinephrine (Option C) because this patient presents with septic shock requiring urgent vasopressor therapy to restore adequate perfusion and prevent irreversible organ damage. 1

Clinical Reasoning

This patient demonstrates clear septic shock with:

• Persistent hypotension (BP 85/40) despite fluid bolus
• Tachycardia (HR 120)
• Fever (101.5°F)
• Signs of infection (cough, malaise)
• High-risk source (assisted-living facility resident) 1

Early identification of sepsis and prompt administration of vasopressors is mandatory when hypotension persists after initial fluid resuscitation. 1 The target mean arterial pressure should be restored to 65-70 mmHg as the initial hemodynamic goal. 1

Why Norepinephrine First

Norepinephrine is the first-choice vasopressor for septic shock with strong evidence (Grade 1B recommendation). 1 It is more efficacious than dopamine and more effective for reversing hypotension in septic shock patients. 1

The Surviving Sepsis Campaign guidelines explicitly state that norepinephrine should be used as the first-line vasopressor to maintain MAP ≥65 mmHg. 1 This recommendation is based on superior outcomes compared to alternative agents, with dopamine causing more tachycardia and arrhythmias. 1

Why Not the Other Options

Option A (Airborne Precautions/RVP Testing)

While respiratory symptoms are present, the immediate life-threatening issue is circulatory collapse requiring vasopressor support. 1 Infection source control and diagnostics are important but secondary to hemodynamic stabilization. 1

Option B (Metronidazole for Bowel Perforation)

There is no clinical evidence of bowel perforation (no peritoneal signs mentioned, nausea/vomiting alone insufficient). Broad-spectrum antibiotics should be administered within 1 hour of septic shock recognition, but the specific choice should target the most likely source. 1 This patient's presentation (cough, fever from assisted-living facility) suggests respiratory or urinary source, not intra-abdominal. 1

Option D (Loperamide for Gastroenteritis)

Antidiarrheal agents are contraindicated in septic shock and do not address the underlying circulatory failure. 1 This represents a dangerous delay in appropriate therapy.

Critical Implementation Steps

All patients requiring vasopressors should have an arterial catheter placed as soon as practical for continuous blood pressure monitoring. 1 Central venous access is necessary for safe norepinephrine administration, though peripheral administration can be used temporarily if central access is delayed. 1

Initial fluid resuscitation should achieve a minimum of 30 mL/kg of crystalloids in the first 3 hours, with more rapid administration needed in some patients. 1 However, when hypotension persists despite fluid bolus (as in this case), vasopressor therapy must not be delayed. 1

Common Pitfalls to Avoid

• Do not delay vasopressor initiation waiting for "adequate" fluid resuscitation when profound hypotension exists. 1 Prolonged hypotension independently increases mortality. 1
• Do not use dopamine as first-line therapy—it is associated with higher mortality and more arrhythmias compared to norepinephrine. 1
• Do not use low-dose dopamine for renal protection—this has no benefit and is strongly discouraged (Grade 1A). 1
• Avoid fluid overload in septic patients, which can worsen outcomes through increased intra-abdominal pressure and pulmonary edema. 1

Subsequent Management Priorities

After initiating norepinephrine:

• Administer broad-spectrum antibiotics within 1 hour of septic shock recognition (Grade 1B). 1
• Obtain blood cultures before antibiotics when possible, but do not delay antibiotic administration. 1
• If vasopressin is needed for refractory hypotension, add it at 0.03 units/minute rather than escalating norepinephrine excessively. 1
• Consider epinephrine as an additional agent if blood pressure remains inadequate despite norepinephrine and vasopressin. 1