What is the management for an 18-year-old with shock, hypoglycemia, polyuria, constipation, and fever?

Management of an 18-Year-Old with Shock, Hypoglycemia, Polyuria, Constipation, and Fever

This patient requires immediate aggressive fluid resuscitation with isotonic crystalloids, urgent correction of hypoglycemia with dextrose, and empiric broad-spectrum antibiotics within 1 hour, as this presentation is most consistent with septic shock. 1, 2

Immediate Resuscitation (First 5 Minutes)

Correct hypoglycemia immediately with intravenous dextrose—this is a critical therapeutic endpoint that must be addressed before anything else, as hypoglycemia can cause cardiac arrest and death. 1, 3, 2, 4

• Administer 20 mL/kg boluses of isotonic saline (0.9% normal saline or Ringer's lactate) rapidly over 5-10 minutes. 1, 2
• Continue fluid boluses up to 40-60 mL/kg in the first hour unless signs of fluid overload (rales, hepatomegaly) develop. 1, 2
• Correct hypocalcemia simultaneously—check ionized calcium and replace if low, as this is another critical therapeutic endpoint in shock. 1, 3
• Obtain blood cultures, then administer broad-spectrum antibiotics within 1 hour of presentation. 1, 2

Antibiotic Selection

• Start ceftriaxone 100 mg/kg/day IV (or 2g IV for this 18-year-old). 2
• Add vancomycin 15 mg/kg IV q6h if MRSA is suspected based on local epidemiology or recent healthcare exposure. 2

Fluid Refractory Shock (15-60 Minutes)

If shock persists after 40-60 mL/kg fluid resuscitation, begin inotropic/vasopressor support immediately—do not delay for central access if peripheral IV is available. 1, 2

Determine Shock Phenotype and Treat Accordingly:

For "cold shock" (cool extremities, weak pulses, elevated SVR):

• Start dopamine 5-10 mcg/kg/min centrally, or epinephrine 0.05-0.3 mcg/kg/min if dopamine-resistant. 1, 2
• Target hemoglobin ≥10 g/dL during active resuscitation with low ScvO2 (<70%). 1

For "warm shock" (warm extremities, bounding pulses, low SVR):

• Start norepinephrine 0.05-0.3 mcg/kg/min. 1

Catecholamine-Resistant Shock (After 60 Minutes)

Administer hydrocortisone 2 mg/kg IV if shock remains refractory to fluids and catecholamines, particularly if absolute adrenal insufficiency is suspected. 1, 2

• Monitor central venous pressure and target ScvO2 >70%. 1
• Maintain hemoglobin ≥10 g/dL during resuscitation phase. 1

Glycemic Management

Target blood glucose <180 mg/dL but avoid hypoglycemia—glucose infusion must accompany insulin therapy in this age group. 1

• Provide continuous glucose delivery at 4-6 mg/kg/min (using dextrose 10% in normal saline) to prevent recurrent hypoglycemia. 1
• Monitor blood glucose frequently (every 1-2 hours initially) as drug metabolism is reduced in severe sepsis, increasing risk of hypoglycemia. 1

Critical Pitfall to Avoid:

Do not use insulin without concurrent glucose infusion in pediatric/young adult patients—some patients make no endogenous insulin while others are insulin-resistant, making hypoglycemia unpredictable and potentially fatal. 1

Addressing Polyuria and Constipation

The polyuria likely represents osmotic diuresis from hyperglycemia (if this occurred before presentation) or post-obstructive diuresis. 5

• Do not restrict fluids to address polyuria—continue aggressive resuscitation as outlined above. 1
• Once shock resolves and the patient is hemodynamically stable, use diuretics if fluid overload develops (>10% total body weight gain). 1
• The constipation is likely secondary to dehydration and will improve with fluid resuscitation—do not prioritize this during acute resuscitation. 5

Source Control

Identify and control the source of infection urgently—this is essential for survival. 2

• Obtain imaging (chest X-ray, abdominal ultrasound/CT) to identify occult abscess, pneumonia, or other infectious source. 2
• Surgical consultation if intra-abdominal source suspected. 2

Monitoring Parameters

• Continuous vital signs, ECG, pulse oximetry. 3, 2
• Urine output (target >1 mL/kg/h). 3, 2
• Serial blood glucose, lactate, electrolytes (especially calcium, sodium, potassium). 3, 2
• Mental status and capillary refill (<2 seconds is goal). 3, 2

Differential Diagnosis Consideration

While septic shock is most likely given fever and shock, the constellation of hypoglycemia, polyuria, and constipation could suggest:

• Hyperosmolar hyperglycemic state (but hypoglycemia at presentation argues against this). 5
• Adrenal crisis (which would explain hypoglycemia, shock, and GI symptoms—another reason to give hydrocortisone if catecholamine-resistant). 1
• Diabetic ketoacidosis (but again, hypoglycemia at presentation is atypical unless over-treated). 6, 5

The presence of fever strongly suggests sepsis as the primary process, with hypoglycemia resulting from sepsis-induced metabolic derangement and inadequate glucose intake. 2

Nutritional Support

Once hemodynamically stable, begin enteral nutrition if tolerated; if not, provide parenteral nutrition. 1

• Enteral feeding is preferred to reduce infection risk. 1
• Ensure adequate glucose delivery (4-6 mg/kg/min) to prevent recurrent hypoglycemia. 1