Management of Septic Shock with Multiple Comorbidities in a 76-Year-Old Male
Critical Assessment and Immediate Priorities
Continue aggressive septic shock management with current broad-spectrum antibiotics (Piperacillin-Tazobactam and Azithromycin), maintain norepinephrine targeting MAP ≥65 mmHg, and address the recurrent hypoglycemia by reducing insulin glulisine doses while monitoring blood glucose every 1-2 hours. 1, 2
The patient presents with septic shock from complicated UTI with multiple high-risk features: advanced age, severe CKD (stage IV), AKI stage III, HFpEF, permanent AF, and CAD. The combination of CHF and AKI significantly increases septic shock risk and mortality in UTI patients. 3
Antimicrobial Management
Current Antibiotic Regimen Assessment
Continue Piperacillin-Tazobactam as empiric broad-spectrum coverage for complicated UTI with septic shock, ensuring activity against all likely pathogens including resistant gram-negatives. 1
Maintain Azithromycin as part of the empiric regimen until pathogen identification and sensitivities are available. 1
Plan to narrow antimicrobial therapy once culture results and sensitivities are established, typically after 48-72 hours. 1
Target 7-10 days total antibiotic duration guided by clinical response and source control adequacy. 1
Nephrotoxicity Monitoring
Monitor renal function closely given the patient's baseline CKD stage IV and current AKI stage III, as Piperacillin-Tazobactam requires dose adjustment for creatinine clearance <40 mL/min. 4
Avoid aminoglycosides despite their traditional role in septic shock, given the patient's severe renal impairment and high risk of further nephrotoxicity. 4
Hemodynamic Management
Vasopressor Strategy
The patient's current BP of 100/60 mmHg suggests adequate MAP (approximately 73 mmHg), but continuous monitoring is essential given the septic shock diagnosis.
Norepinephrine remains the first-line vasopressor with target MAP ≥65 mmHg, administered through central venous access with arterial line monitoring. 1, 5, 6
If MAP falls below 65 mmHg despite norepinephrine, add vasopressin at 0.03 units/minute rather than escalating norepinephrine dose further. 1, 5, 6
Never exceed vasopressin 0.03-0.04 units/minute except as salvage therapy, due to risk of cardiac, digital, and splanchnic ischemia. 1, 5, 6
If hypotension persists despite norepinephrine plus vasopressin, add epinephrine 0.05-2 mcg/kg/minute as third-line agent. 5, 6
Avoid dopamine due to increased mortality and arrhythmias compared to norepinephrine, particularly problematic given the patient's permanent AF and CAD. 1, 5, 6
Cardiac Considerations in HFpEF
Continue beta-blockers (if currently prescribed) unless acute hemodynamic decompensation or cardiogenic shock develops. 1
Consider dobutamine 2.5-20 mcg/kg/minute only if persistent hypoperfusion exists despite adequate MAP and fluid resuscitation, particularly if myocardial dysfunction is evident. 1, 5, 6
Norepinephrine is safe in HFpEF and actually improves renal blood flow in sepsis despite typical renal vasoconstriction in other contexts. 6
Fluid Management
Resuscitation Protocol
The patient has received adequate initial fluid resuscitation based on I/O data showing positive balance over 24 hours (2420 in/1860 out on 1/2,2105 in/1890 out on 01/01). 1, 7
Use crystalloids (normal saline or balanced solutions like Ringer's lactate) for any additional fluid requirements. 1
Consider albumin supplementation if substantial additional crystalloids are needed, given the patient's critical illness. 1
Avoid hydroxyethyl starches completely due to increased mortality and renal replacement therapy risk in septic shock. 1, 7
Fluid Balance in HFpEF and AKI
Monitor for fluid overload carefully given HFpEF, using clinical examination (jugular venous distension, pulmonary crackles, peripheral edema) and hemodynamic parameters. 1
Continue fluid administration only as long as hemodynamic improvement occurs, based on pulse pressure, stroke volume variation, arterial pressure, heart rate, mental status, and urine output. 1, 7
Stop fluid administration when no improvement in tissue perfusion occurs, signs of fluid overload develop, or hemodynamic parameters stabilize. 7
Hypoglycemia Management
Immediate Insulin Adjustment
The recurrent hypoglycemia (CBG 73,75 mg/dL) represents a critical safety issue requiring immediate intervention. 1, 2
Reduce insulin glulisine doses immediately given the patient's AKI stage III and CKD stage IV, which significantly increase hypoglycemia risk. 2
Target blood glucose 140-180 mg/dL rather than tight glycemic control, per Surviving Sepsis Campaign guidelines for ICU patients with sepsis. 1
Monitor blood glucose every 1-2 hours until glucose values and insulin infusion rates are stable, then every 4 hours thereafter. 1, 2
Use arterial blood rather than capillary blood for point-of-care glucose testing if arterial catheter is in place, as capillary measurements may not accurately estimate arterial/plasma glucose. 1
Risk Factors for Hypoglycemia
Renal impairment (AKI III + CKD IV) dramatically increases hypoglycemia risk due to decreased insulin clearance and impaired gluconeogenesis. 2
Septic shock increases insulin sensitivity and reduces caloric intake, further predisposing to hypoglycemia. 1
Multiple medications may potentiate hypoglycemia, including ACE inhibitors (if prescribed for HFpEF/CAD), though none are explicitly listed in the current medication regimen. 2
Treatment of Hypoglycemia
For mild hypoglycemia (conscious, able to swallow): administer oral glucose. 2
For severe hypoglycemia (altered mental status, seizure): administer glucagon or concentrated intravenous glucose (D50). 2
Sustained carbohydrate intake and observation are necessary because hypoglycemia may recur after apparent clinical recovery. 2
Renal Replacement Therapy Considerations
Indications for RRT
Do not initiate RRT solely for elevated creatinine or oliguria without other definitive indications (severe hyperkalemia, refractory acidosis, uremic complications, severe fluid overload). 1
If RRT becomes necessary, either continuous renal replacement therapy (CRRT) or intermittent hemodialysis are equivalent in sepsis with AKI. 1
Prefer CRRT over intermittent hemodialysis to facilitate fluid balance management in this hemodynamically unstable patient with septic shock. 1
Monitoring Parameters
Monitor potassium closely given CKD stage IV, AKI stage III, and potential for hyperkalemia from tissue breakdown in sepsis. 1
Avoid bicarbonate therapy for pH ≥7.15, as it does not improve hemodynamics or reduce vasopressor requirements in hypoperfusion-induced lactic acidemia. 1
Blood Pressure Management in HFpEF
Hypertension Control
The elevated BP mentioned in the history (though current BP is 100/60) requires careful management given HFpEF and CAD. 1
Target systolic BP <130 mmHg once septic shock resolves, using guideline-directed medical therapy (ACE inhibitors/ARB, beta-blockers, MRA). 1
Prioritize ACE inhibitors or ARB, then beta-blockers, then MRA for hypertension management in HFpEF patients. 1
Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in HFpEF with AF, as they should not be combined with beta-blockers. 1
Atrial Fibrillation Management
Rate Control Strategy
Continue beta-blockers for rate control unless hemodynamic instability develops. 1
Target heart rate 60-100 bpm (current rate 86 bpm is acceptable). 1
Digoxin may be added as adjunctive therapy if rate control is inadequate with beta-blockers alone. 1
Anticoagulation
Maintain systemic anticoagulation for permanent AF unless contraindicated by active bleeding or severe coagulopathy. 1
Prefer novel oral anticoagulants over warfarin in nonvalvular AF, though this may need adjustment for severe CKD. 1
Urinary Catheter Management
Source Control
The indwelling Foley catheter (IFC) is a potential ongoing source of infection and should be evaluated for removal once hemodynamically stable. 1
Flushing with 20cc as performed by surgery addresses catheter patency but does not eliminate the infection source. 1
Solifenacin initiated by surgery is appropriate for BPH management but does not address the acute infection. 1
Supportive Care Measures
VTE Prophylaxis
Administer pharmacologic VTE prophylaxis with low-molecular-weight heparin (LMWH) daily, using dalteparin or another form with low renal metabolism given CKD stage IV. 1
If creatinine clearance <30 mL/min, use dalteparin specifically or unfractionated heparin. 1
Combine with intermittent pneumatic compression devices whenever possible. 1
Stress Ulcer Prophylaxis
- Administer proton pump inhibitor (Omeprazole already prescribed) for stress ulcer prophylaxis given septic shock and bleeding risk factors. 1
Nutrition
Initiate enteral feeding within 48 hours if tolerated, rather than complete fasting or IV glucose only. 1
Use low-dose feeding (up to 500 calories/day initially), advancing only as tolerated. 1
Avoid total parenteral nutrition in favor of enteral route. 1
Do not restrict protein to delay RRT initiation, as patients with AKI are highly catabolic. 1
Common Pitfalls to Avoid
Never use low-dose dopamine for "renal protection"—this is strongly contraindicated and offers no benefit. 1, 5, 6
Do not escalate vasopressin beyond 0.03-0.04 units/minute except as salvage therapy. 1, 5, 6
Avoid phenylephrine except when norepinephrine causes serious arrhythmias or as salvage therapy. 1, 5, 6
Do not delay antimicrobial administration—time from presentation to first antibiotic dose should not exceed one hour. 1, 8
Never use hydroxyethyl starches for fluid resuscitation in septic shock. 1, 7
Avoid tight glycemic control (target <110 mg/dL)—target 140-180 mg/dL instead to reduce hypoglycemia risk. 1