MKSAP Quiz: confusion, fever and flank pain
Hospitalizations for diabetes increase, especially among younger women
A 71-year-old woman is brought to the emergency department from a nursing home because of confusion, fever and flank pain. Her temperature is 38.5 °C (101.3 °F), blood pressure is 82/48 mm Hg, pulse rate is 123/min, and respiration rate is 27/min. Mucous membranes are dry, and there is costovertebral angle tenderness, poor skin turgor, and no edema. Hemoglobin concentration is 10.5 g/dL (105 g/L), leukocyte count is 15,600/µL (15.6 × 109/L); urinalysis reveals 50 to 100 leukocytes/hpf and many bacteria/hpf. The patient has an anion gap metabolic acidosis. A central venous catheter is placed, and antibiotic therapy is started.
Which of the following additional interventions is most likely to improve survival for this patient?
A. Aggressive fluid resuscitation
B. Hemodynamic monitoring with a pulmonary artery catheter
C. Maintaining hemoglobin concentration above 12 g/dL (120 g/L)
D. Maintaining Pco2 below 50 mm Hg (6.65 kPa)
MKSAP Answer and Critique
The correct answer is A) Aggressive fluid resuscitation. This item is available to MKSAP 15 subscribers as item 99 in the Pulmonology and Critical Care Medicine module.
The patient has severe sepsis presumptively from pyelonephritis. Aggressive fluid resuscitation with resolution of lactic acidosis within 6 hours would have a beneficial effect on this patient's survival. Resuscitation of the circulation should target a central venous oxygen saturation (Scvo2) or mixed venous oxygen saturation (Svo2) of at least 70%. Other reasonable goals include a central venous pressure of 8 to 12 mm Hg, a mean arterial pressure of at least 65 mm Hg, and a urine output of at least 0.5 mL/kg/h. In patients such as the one presented, this often translates into administration of 5 to 6 L of fluid. Timing of resuscitation matters to survival. In a landmark study by Rivers and colleagues, early goal-directed therapy that included interventions within the first 6 hours to maintain a Scvo2 of greater than 70% and to resolve lactic acidosis resulted in higher survival rates than more delayed resuscitation attempts. Over the first 72 hours, patients in the control arm received the same quantity of fluid for resuscitation, but they had a significantly higher likelihood of dying by discharge or at 60 days.
Crystalloid is given much more frequently than colloid, and there are no data to support routinely using colloid in lieu of crystalloid. Blood transfusion may be part of resuscitation for anemic patients in shock, but maintaining hemoglobin levels above 12 g/dL (120 g/L) is not supported by evidence. In stable patients who are not in shock, a transfusion threshold of 7 g/dL (70 g/L) is an acceptable conservative approach. There are no data to support that maintaining a lower Pco2 or using a pulmonary artery catheter would help to increase survival in this patient.
Key Point
- In patients with severe sepsis, early goal-directed therapy within the first 6 hours to maintain a central venous or mixed venous oxygen saturation of greater than 70% and to resolve lactic acidosis improves survival compared with more delayed resuscitation attempts.