From the Guidelines
I strongly recommend giving a 500-1000 mL fluid bolus of normal saline or lactated Ringer's solution and repeating a lactic acid level. The patient is showing signs of ongoing sepsis with persistent tachycardia (HR 110-120s), fever (though improved from 101.5°F to 100.1°F after Tylenol), and borderline blood pressure (MAP 75). While the antibiotics are appropriate and should be administered as scheduled, the tachycardia despite pain control suggests possible hypovolemia or ongoing inflammatory response. Fluid resuscitation is a cornerstone of sepsis management and may help stabilize her hemodynamics, as recommended by the Surviving Sepsis Campaign guidelines 1. A repeat lactic acid level will help assess if tissue perfusion is improving or worsening, guiding further management decisions.
Some key points to consider in the management of this patient include:
- The importance of fluid resuscitation in sepsis management, with a recommended initial fluid bolus of at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1
- The need for frequent reassessment of hemodynamic status to guide further fluid management 1
- The use of lactic acid levels to monitor tissue perfusion and guide management decisions 1
- The importance of administering effective IV antimicrobials within the first hour of recognition of septic shock or severe sepsis 1
After the bolus, reassess vital signs, particularly heart rate and blood pressure, to determine if additional interventions are needed. Continue to monitor urine output as well, as this provides information about renal perfusion and overall volume status. The patient should still be transferred to the 4th floor after stabilization, but addressing these acute changes is appropriate before transfer.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Status
- The patient's temperature has decreased from 101.5 to 100.1 after administration of Tylenol, dilaudid, and compazine.
- The patient's heart rate remains elevated at 110-120s.
- The patient's blood pressure is 108/63 with a mean arterial pressure (MAP) of 75.
- The patient reports that their pain is slightly better.
Treatment Considerations
- Administration of antibiotic azactam is due and will be given to the patient.
- The possibility of a bolus of fluids is being considered to help manage the patient's condition.
- Repeating lactic acid levels may be necessary to monitor the patient's response to treatment.
Relevant Research
- A study on heart rate control in shock found that elevated heart rates in septic shock are associated with inefficient hemodynamics, worsening perfusion, and organ function, as well as an unfavorable prognosis 2.
- Research on fluid resuscitation in sepsis suggests that balanced crystalloids or albumin may be associated with reduced mortality compared to other fluids 3, 4.
- A review of sepsis and septic shock emphasizes the importance of early recognition and treatment with antibiotics, fluids, and vasopressors to reduce organ system injury and mortality 5.
- A discussion on sepsis management highlights the need for a nuanced understanding of lactate physiology and the importance of early recognition and intervention in sepsis management 6.