What is the next step in management for an elderly patient with sepsis, hypotension, and no response to initial fluid resuscitation and broad-spectrum antibiotics?

Norepinephrine (Option B)

The appropriate next therapy is norepinephrine, as this patient has persistent hypotension despite adequate initial fluid resuscitation (30 mL/kg), indicating septic shock that requires immediate vasopressor support to restore perfusion pressure and prevent end-organ damage. 1

Rationale for Vasopressor Initiation

This elderly patient meets criteria for septic shock with:

• Persistent hypotension (BP 82/62, MAP approximately 69 mmHg, which is below the target of ≥65 mmHg) despite receiving the recommended 30 mL/kg fluid bolus 1
• Tachycardia (P 126) and fever (39.9°C) consistent with distributive shock
• No hemodynamic improvement after initial resuscitation

The Surviving Sepsis Campaign strongly recommends norepinephrine as the first-choice vasopressor in septic shock (strong recommendation, moderate quality evidence). 1 When adequate fluid resuscitation fails to restore hemodynamic stability, vasopressor therapy should be initiated immediately rather than administering additional fluid boluses. 1

Why Not Additional Crystalloids (Option A)

Lactated Ringer's solution represents additional crystalloid administration, which is inappropriate at this juncture because:

• The patient has already received the guideline-recommended initial fluid challenge of 30 mL/kg 1
• Vital signs remain unchanged, indicating the patient is likely no longer fluid-responsive 1
• Continuing fluid administration without hemodynamic improvement risks fluid overload, pulmonary edema, and worsening outcomes 2, 3
• The fluid challenge technique should only continue "as long as hemodynamic factors continue to improve"—this patient shows no improvement 1

Recent evidence demonstrates that physiologically-informed resuscitation using dynamic assessments of fluid responsiveness results in lower net fluid balance and reduced risk of renal and respiratory failure compared to continued empiric fluid administration. 3

Why Not Packed Red Blood Cells (Option C)

There is no indication for transfusion in this scenario:

• No mention of anemia, bleeding, or hemoglobin level
• The hypotension is due to vasodilatory shock from sepsis, not hemorrhagic shock
• Transfusion would not address the underlying pathophysiology of distributive shock

Why Not Sodium Bicarbonate (Option D)

Sodium bicarbonate has no role in the acute management of septic shock:

• Not recommended by any sepsis guidelines for hemodynamic support 1
• Does not address the vasodilatory pathophysiology
• May be considered in specific metabolic scenarios (severe metabolic acidosis), but this is not the immediate priority for hemodynamic stabilization

Norepinephrine Administration

Norepinephrine should be initiated immediately with a target MAP of ≥65 mmHg. 1, 4 The typical starting dose is 2-3 mL/minute (8-12 mcg/minute) of a standard dilution (4 mg in 1000 mL of 5% dextrose), then titrated to achieve the MAP target. 5

If MAP target is not achieved with norepinephrine alone, add vasopressin (0.03 units/minute) or epinephrine as a second-line agent. 1, 4 This combination approach can either raise MAP to target or decrease norepinephrine requirements. 1

Critical Implementation Points

• Establish arterial line monitoring as soon as practical for accurate blood pressure monitoring during vasopressor titration 1
• Administer through a large central vein when possible to minimize risk of extravasation and tissue necrosis 5
• Avoid leg veins in elderly patients due to increased risk of gangrene from underlying occlusive vascular disease 5
• Monitor for signs of excessive vasoconstriction: check extremity perfusion, urine output (target ≥0.5 mL/kg/h), lactate clearance, and mental status 6, 7

Additional Considerations

If hemodynamic stability cannot be achieved with adequate fluid resuscitation and vasopressor therapy, consider adding hydrocortisone 200 mg/day. 1, 6 This is particularly relevant if the patient requires high-dose norepinephrine or remains refractory to initial vasopressor therapy. 1, 6

Reassess for occult sources of infection requiring source control, as persistent shock despite appropriate resuscitation may indicate inadequate source control. 1

Early vasopressor administration (within the first hour) may have advantages including faster achievement of MAP targets, reduced fluid overload risk, and potentially improved outcomes compared to delayed initiation. 2