Septic Shock
Septic Shock
Septic Shock
air entry. Patients with sepsis have a decreased anesthetic require- references
ment, thus, maintenance of anesthesia was achieved using Sevo- 1. Eissa D, Carton EG, and Buggy DJ. Anaesthetic management
flurane at a concentration of 1% end-tidal Sevoflurane, which is of patients with severe sepsis. Br J Anaesth. 2010 Oct; 105 (6):
one half its minimal alveolar concentration.2 SMs ETCO2 was 21 734743.
mmHg, indicating poor perfusion likely due to decreased cardiac 2. Yoon SH. Concerns of the anesthesiologist: anesthetic induc-
output and developing pulmonary edema secondary to acute respi- tion in severe sepsis or septic shock patients. Korean J Anes-
ratory distress syndrome (ARDS). Phenylephrine 200 mcg, a pure thesiol. 2012 Jul; 63 (1): 310.
alpha-1 agonist was administered, with little to no effect. Another 3. Kalra OP, Raizada A. Approach to a patient with urosepsis. J
300 mcg was given with no observable clinical effect. Glob Infect Dis. 2009 Jan-Jun; (1) :5763.
SM was now markedly hypotensive at 70/35 mmHg as per the 4. Daabis M. American society of anaesthesiologists physical
arterial line. Treatment for pulmonary edema caused by ARDS is status classification. Indian J Anaesth. 2011 MarApr; 55 (2):
positive end expiratory pressure (PEEP), but PEEP decreases ve- 111115.
nous return and results in hypotension. At this point, the need for 5. McGhee BH, Bridges EJ. Monitoring arterial blood pressure:
adequate ventilation did not outweigh the need for hemodynamic what you may not know. Crit Care Nurse. 2002 April; 22 (2):
stability. Vasopressin was considered but ultimately was not admin- 6079.
istered in favour of more powerful direct acting inotropes. 10 mcg 6. Chan CM, Mitchell AL, Shorr AF. Etomidate is associated with
of IV epinephrine was administered in conjunction with a fluid bo- mortality and adrenal insufficiency in sepsis: a meta-analysis.
lus. The radiologist began to scrub for the procedure. SM developed Crit Care Med. 2012 Nov; 40(11): 294553.
tachycardia at 145 bpm, with a BP 55/30 mmHg. SpO2 was 78%.
Sevoflurane was switched off; oxygen at 100%, flows at 15 L/min.
IV epinephrine was increasingly administered in 10 mcg boluses
escalating to 30 mcg boluses. BP improved slightly to 70/40 mmHg.
An infusion of epinephrine/norepinephrine was established.
The anesthesiologist advised the radiologist that the patient
was too unstable for the procedure. SMs coagulopathy and sep-
sis were far too severe, and in the event of blood loss the risk for
mortality was greatly increased.2 SM was transferred to the MSICU
on the infusion of epinephrine/norepinephrine and cardiac moni-
tors. SM was started on continuous renal replacement therapy and
maintained on an epinephrine/norepinephrine infusion. 24 hours
later, the ureteric stents were changed at the bedside in the MSICU.
Prior to the procedure, SM received DDAVP (Vasopressin) 20 mcg
IV and Vitamin K 10 mg IV for her coagulopathy. The procedure
was a success and the patients coagulopathy started to resolve. SM
remained in the MSICU for 4 days requiring decreasing doses of
pressors. After a 24 day stay, she improved markedly and was dis-
charged home in stable condition.
discussion
This case presented some difficult decisions from a manage-
ment perspective. As always it is important to remember that phy-
sicians inadvertently can cause harm to their patient(s). From iatro-
genic infections, to ill-informed decision making, in some cases, the
gold standard treatment for the patient may result in deleterious
consequences. In SMs case, the decision to forego the procedure
in the face of marked hypoxemia and hypotension was the most ap-
propriate management. In the event that plan A begins to fail, plan
B must already be formulated and ready to implement, while re-
membering: First, do no harm.