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