List the possible reasons why a patient with septic shock from infected pancreatitis may have ongoing hypotension despite intravenous fluid therapy, antibiotics and escalating inotrope requirement.

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College Answer

Primary problem not fixed 
•    Untreated focus of infection/ inadequate  primary source control eg pancreatic abscess, infected pseudocyst
•    New  sepstic  site  eg  central  line/  hospital  acquired  pneumonia  /cholecystitis, urinary tract

Systematic Approach 
“hypovolaemic/ obstructive/ cardiac/ distributive +/- endocrine

•    Hypovolaemia  or hidden  bleeding     eg. From surgical  site/ peptic ulcer, “third space” losses (eg ascites from peritonitis)

•    Undiagnosed  or new     “obstructive  shock” :Tension pneumothorax/  Pericardial effusion/gas trapping (auto PEEP)/ pleural effusions/ pulmonary emboli

•    Severe Intra abdominal hypertension

•    Dysrhythmia eg SVT, junctional rhythm etc
•    New myocardial ischaemia
•    New/ undiagnosed cardiac valve pathology

•    Severe adrenal/ pituitary/thyroid dysfunction.
•    Drug reaction/ anaphylaxis
•    Vitamin deficiency (B1)
•    Electrolyte abnormalities such as hypophosphataemia  and hypocalcaemia (the latter particularly with pancreatitis)

Technical

•    CVL fallen out or not in a central vein / no pressors in the infusion bag
•    Measurement   error  –  eg  arterial  line  not  zeroed/under   or  over  damped, transducer height, wrong NIBP cuff size  etc

Miscellaneous

•    Radial/ central arterial monitoring discrepancy with severe vasoconstriction
•    Upper limb vascular disease (radial arterial line) or obstruction (eg dissection or aorto-occlusive disease: femoral arterial line)
•    Anti hypertensive drugs taken as part of patients usual medications

Discussion

This question is identical to Question 17 from the second paper of 2013.