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 e.g. pancreatic abscess, infected pseudocyst.
New septic site e.g. central line/ hospital acquired pneumonia / cholecystitis, urinary tract.
Systematic approach i.e. Hypovolaemic / obstructive / cardiogenic / distributive +/- endocrine etc.
Technical:
CVL fallen out or not in a central vein / no pressors in the infusion bag
Measurement error – e.g. 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 (e.g. dissection or aorto-occlusive disease: femoral arterial line)
Anti hypertensive drugs taken as part of patients usual medications
This question does not rely on published evidence, but rather tests the candidate's ability to reason through shock in a systematic fashion.
If one were to approach it like a normal list of differentials, it would look like this:
Measurement artifact
Vascular causes
Infectious causes
Inflammatory causes
Drug-induced causes
Traumatic causes
Endocrine causes
If one were to approach it like any shock, it would look like this:
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Yealy, Donald M., et al. "A randomized trial of protocol-based care for early septic shock." The New England journal of medicine 370.18 (2014): 1683-1693.