What is the next step for a patient with hypotension, presenting with chills, rigor, and a history of cough and sputum production?

Immediate Management: Fluid Resuscitation First

In a patient presenting with hypotension (90/70 mmHg), chills, rigor, and recent respiratory symptoms suggesting sepsis, the next step is B) fluid resuscitation with crystalloids, followed immediately by antibiotics if hypotension persists after initial fluid challenge. 1

Initial Resuscitation Protocol

This patient meets criteria for severe sepsis/septic shock based on:

• Suspected infection (cough, sputum production suggesting pneumonia) 1
• Systolic blood pressure ≤90 mmHg indicating sepsis-induced hypotension 1, 2
• Chills and rigors indicating systemic inflammatory response 1

The Surviving Sepsis Campaign guidelines mandate protocolized quantitative resuscitation starting immediately upon recognition of sepsis-induced tissue hypoperfusion, which should NOT be delayed pending ICU admission. 1

Step 1: Aggressive Fluid Resuscitation

• Administer 30 mL/kg of crystalloid fluid (approximately 2-3 liters for average adult) as a rapid bolus within the first 3 hours 1, 3
• Lactated Ringer's solution is preferred over 0.9% saline, as it is associated with improved survival (adjusted HR 0.71,95% CI 0.51-0.99) and more hospital-free days in sepsis-induced hypotension 4
• Fluid resuscitation should occur intravenously, even if surgical cut-down or intraosseous access is required 1

Step 2: Simultaneous Antibiotic Administration

• Obtain blood cultures (minimum two sets) but do NOT delay antibiotics beyond 45 minutes 5
• Administer IV broad-spectrum antibiotics within 60 minutes of sepsis recognition, as each hour of delay increases mortality risk 5
• For suspected pneumonia with sepsis, cover typical and atypical respiratory pathogens 5

Step 3: Reassess After Fluid Challenge

After the initial 30 mL/kg crystalloid bolus, reassess blood pressure: 1, 2

• If systolic BP remains <90 mmHg or MAP <65 mmHg despite adequate fluid resuscitation (defined as 30 mL/kg), initiate vasopressor therapy 1, 2
• Norepinephrine is the first-line vasopressor 1, 3
• Target MAP ≥65 mmHg 1, 3

Why NOT Epinephrine First?

IV epinephrine (option C) is NOT the initial intervention for septic shock. 1

• Epinephrine is reserved for refractory hypotension when norepinephrine fails or as a single agent when myocardial depression is present 1
• In distributive shock from sepsis, norepinephrine is the recommended first-line vasopressor after adequate fluid resuscitation 1
• Vasopressors should only be initiated AFTER demonstrating inadequate response to fluid challenge 1, 2

Resuscitation Targets (First 6 Hours)

Monitor and target the following parameters: 1

• MAP ≥65 mmHg 1, 3
• Urine output ≥0.5 mL/kg/h 1
• CVP 8-12 mmHg (12-15 mmHg if mechanically ventilated) 1
• ScvO2 ≥70% or lactate normalization 1, 3

Critical Pitfalls to Avoid

• Do NOT delay antibiotics for diagnostic workup—sepsis management takes precedence 5
• Do NOT start vasopressors before adequate fluid resuscitation (30 mL/kg crystalloid challenge) 1, 2
• Do NOT use 0.9% saline preferentially—lactated Ringer's has superior outcomes 4
• Stop fluid resuscitation if no improvement in tissue perfusion occurs or if pulmonary edema develops (crepitations on exam) 1
• Some patients may require several liters during the first 24-48 hours—the initial 30 mL/kg is just the starting point 1

Monitoring Response to Fluid Resuscitation

Positive response indicators include: 1

• ≥10% increase in systolic/mean arterial blood pressure 1
• ≥10% reduction in heart rate 1
• Improvement in mental status, peripheral perfusion, and/or urine output 1

If these improvements occur, continue fluid resuscitation cautiously while monitoring for fluid overload. 1