Sepsis

Sepsis US Medical PG Question 1: A 70-year-old woman is on hospital day 2 in the medical intensive care unit. She was admitted from the emergency department for a 2-day history of shortness of breath and fever. In the emergency department, her temperature is 39.4°C (103.0°F), the pulse is 120/min, the blood pressure is 94/54 mm Hg, the respiratory rate is 36/min, and oxygen saturation was 82% while on 4L of oxygen via a non-rebreather mask. Chest X-ray shows a right lower lobe consolidation. She was intubated, sedated, and started on broad-spectrum antibiotics for sepsis of pulmonary origin and intravenous norepinephrine for blood pressure support. Since then, her clinical condition has been stable, though her vasopressor and oxygen requirements have not improved. Today, her physician is called to the bedside because her nurse noted some slow bleeding from her intravenous line sites and around her urinary catheter. Which of the following most likely represents the results of coagulation studies for this patient?

• A. D-dimer: negative, fibrinogen level: low, platelet count: low
• B. D-dimer: elevated, fibrinogen level: normal, platelet count: normal
• C. D-dimer: elevated, fibrinogen level: low, platelet count: low (Correct Answer)
• D. D-dimer: negative, fibrinogen level: elevated, platelet count: elevated
• E. D-dimer: negative, fibrinogen level: normal, platelet count: normal

Sepsis Explanation: ***D-dimer: elevated, fibrinogen level: low, platelet count: low*** - The patient's presentation with **sepsis** requiring intubation and vasopressors, along with diffuse **bleeding from IV sites and urinary catheter**, strongly suggests **disseminated intravascular coagulation (DIC)**. - In DIC, widespread activation of the coagulation cascade leads to consumption of **platelets** and **clotting factors (including fibrinogen)**, resulting in thrombocytopenia and hypofibrinogenemia. The breakdown of clots produces **elevated D-dimer** levels. *D-dimer: negative, fibrinogen level: low, platelet count: low* - A **negative D-dimer** would contradict the diagnosis of DIC, as D-dimer is a product of fibrin degradation and is almost always elevated in DIC due to extensive clot formation and subsequent fibrinolysis. - While low fibrinogen and platelet count are characteristic of DIC, the negative D-dimer makes this option unlikely in the context of active bleeding from multiple sites. *D-dimer: elevated, fibrinogen level: normal, platelet count: normal* - While an **elevated D-dimer** is consistent with fibrinolysis occurring in DIC, normal **fibrinogen** and **platelet counts** would argue against the consumptive coagulopathy that defines DIC. - The presence of diffuse bleeding in a patient with sepsis usually indicates significant depletion of clotting factors and platelets. *D-dimer: negative, fibrinogen level: elevated, platelet count: elevated* - This profile suggests an **inflammatory state** or a hypercoagulable state without significant fibrinolysis or consumption of clotting factors. - A **negative D-dimer** and **elevated fibrinogen/platelets** contradict the signs and symptoms of DIC with active bleeding. *D-dimer: negative, fibrinogen level: normal, platelet count: normal* - This result would be inconsistent with **DIC** and the patient's clinical picture of widespread bleeding. - In DIC, there is active coagulation and fibrinolysis, leading to consumption of platelets and fibrinogen and production of D-dimers.

Sepsis US Medical PG Question 2: A 45-year-old homeless man is brought to the emergency department by the police. He was found intoxicated and passed out in a library. The patient has a past medical history of IV drug abuse, diabetes, alcohol abuse, and malnutrition. The patient has been hospitalized previously for multiple episodes of pancreatitis and sepsis. Currently, the patient is minimally responsive and only withdraws his extremities in response to painful stimuli. His temperature is 99.5°F (37.5°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam is notable for tachycardia, a diastolic murmur at the left lower sternal border, and bilateral crackles on pulmonary exam. The patient is started on IV fluids, vancomycin, and piperacillin-tazobactam. Laboratory values are ordered as seen below. Hemoglobin: 9 g/dL Hematocrit: 30% Leukocyte count: 11,500/mm^3 with normal differential Platelet count: 297,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.0 mEq/L HCO3-: 28 mEq/L BUN: 33 mg/dL Glucose: 60 mg/dL Creatinine: 1.7 mg/dL Ca2+: 9.7 mg/dL PT: 20 seconds aPTT: 60 seconds AST: 1,010 U/L ALT: 950 U/L The patient is admitted to the medical floor. Five days later, the patient's neurological status has improved. His temperature is 99.5°F (37.5°C), blood pressure is 130/90 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 99% on room air. Laboratory values are repeated as seen below. Hemoglobin: 10 g/dL Hematocrit: 32% Leukocyte count: 9,500/mm^3 with normal differential Platelet count: 199,000/mm^3 Serum: Na+: 140 mEq/L Cl-: 102 mEq/L K+: 4.3 mEq/L HCO3-: 24 mEq/L BUN: 31 mg/dL Glucose: 100 mg/dL Creatinine: 1.6 mg/dL Ca2+: 9.0 mg/dL PT: 40 seconds aPTT: 90 seconds AST: 150 U/L ALT: 90 U/L Which of the following is the best description of this patient’s current status?

• A. Recovery from acute renal failure
• B. Acute renal failure
• C. Recovery from ischemic liver disease
• D. Fulminant liver failure (Correct Answer)
• E. Recovery from acute alcoholic liver disease

Sepsis Explanation: ***Fulminant liver failure*** - The patient's **prolonged PT (40 seconds)** and **aPTT (90 seconds)** after 5 days, despite improvements in other parameters, indicate a severe impairment in hepatic synthesis of clotting factors, which is a hallmark of **fulminant liver failure**. - The initial presentation with **elevated AST/ALT (over 1000 U/L)** coupled with **encephalopathy (minimally responsive)** and subsequent worsening coagulopathy points towards acute liver failure, even if transaminases are improving. *Recovery from acute renal failure* - While the initial **creatinine (1.7 mg/dL)** was mildly elevated, it remained largely unchanged (1.6 mg/dL) after 5 days, indicating no significant acute renal failure or subsequent recovery. - The patient’s fluid resuscitation and improved hemodynamics would likely lead to a more pronounced improvement in creatinine if significant acute renal failure had occurred and was recovering. *Acute renal failure* - The creatinine level, while slightly elevated, does not meet the criteria for significant **acute renal failure** (e.g., a >50% increase from baseline or a >0.3 mg/dL increase within 48 hours relative to his baseline, which is unknown but likely lower than 1.7 mg/dL given his other conditions). - Furthermore, if true acute renal failure was present on admission, 5 days later with improved vitals, we would expect a clearer trend of either worsening or recovering creatinine, neither of which is strongly evident here. *Recovery from ischemic liver disease* - While the initial very high transaminases (AST 1010, ALT 950) could suggest **ischemic liver injury**, the subsequent significant prolongation of **PT and aPTT** (from 20 to 40 seconds and 60 to 90 seconds, respectively) indicates worsening synthetic dysfunction, not recovery. - Recovery from ischemic liver disease would typically show improving coagulation parameters alongside decreasing transaminases. *Recovery from acute alcoholic liver disease* - Similar to recovery from ischemic liver disease, recovery from **acute alcoholic liver disease** would involve an improvement in liver synthetic function, reflected by a **shortening of PT/aPTT**, not a progressive prolongation as seen here. - The patient's initial presentation is consistent with acute alcoholic hepatitis or other acute liver injury given his history and high LFTs, but the subsequent worsening coagulopathy rules out recovery.

Sepsis US Medical PG Question 3: A 77-year-old woman is brought to the emergency department from her nursing home because she was found down overnight. On presentation she was found to be delirious and was unable to answer questions. Chart review shows that she is allergic to cephalosporins. Her temperature is 102.2°F (39°C), blood pressure is 105/52 mmHg, pulse is 94/min, and respirations are 23/min. Physical exam reveals a productive cough. A metabolic panel is obtained with the following results: Serum: Na+: 135 mEq/L Cl-: 95 mEq/L K+: 4 mEq/L HCO3-: 19 mEq/L BUN: 40 mg/dL Creatinine: 2.5 mg/dL Glucose: 150 mg/dL Based on these findings two different drugs are started empirically. Gram stain on a blood sample is performed showing the presence of gram-positive organisms on all samples. One of the drugs is subsequently stopped. The drug that was most likely stopped has which of the following characteristics?

• A. Resistance conveyed through acetylation
• B. Associated with red man syndrome
• C. Single-ringed ß-lactam structure (Correct Answer)
• D. Causes discolored teeth in children
• E. Accumulates inside bacteria via O2-dependent uptake

Sepsis Explanation: ***Single-ringed ß-lactam structure*** - The patient presents with **sepsis** due to **pneumonia** likely caused by **gram-positive organisms**. Given a cephalosporin allergy, **aztreonam** (a monobactam) would be an initial empirical antibiotic choice to cover gram-negative bacteria, alongside a drug for gram-positive coverage (like vancomycin). - Since the **blood cultures** confirmed **gram-positive organisms**, the drug covering gram-negative bacteria (aztreonam) would be stopped. Aztreonam is characterized by its **single-ringed β-lactam structure**. *Resistance conveyed through acetylation* - This mechanism of resistance is typical of **aminoglycosides** (e.g., gentamicin) and **chloramphenicol**. - Aminoglycosides were unlikely to be one of the empirically started drugs, as they are often used in combination with β-lactams, and this patient has a cephalosporin allergy. *Associated with red man syndrome* - **Red man syndrome** is a common adverse effect associated with **vancomycin** administration, especially with rapid infusion. - Vancomycin would likely be continued, as it effectively targets gram-positive organisms, including **MRSA**, and is a suitable alternative given the cephalosporin allergy. *Causes discolored teeth in children* - This is a characteristic side effect of **tetracyclines** (e.g., doxycycline), which are contraindicated in young children and pregnant women due to their effects on bone and teeth development. - Tetracyclines are not typically first-line empiric therapy for severe pneumonia or sepsis, especially in an elderly patient. *Accumulates inside bacteria via O2-dependent uptake* - This describes the mechanism of uptake for **aminoglycosides**. Their entry into bacteria is an **energy-dependent process** requiring oxygen. - As mentioned, aminoglycosides are less likely to be the initial drug stopped in this scenario, as they target gram-negative bacteria.

Sepsis US Medical PG Question 4: A 75-year-old male arrives by ambulance to the emergency room severely confused. His vitals are T 40 C, HR 120 bpm, BP 80/55 mmHg, RR 25. His wife explains that he injured himself about a week ago while cooking, and several days later his finger became infected, oozing with pus. He ignored her warning to see a doctor and even refused after he developed fever, chills, and severe fatigue yesterday. After being seen by the emergency physician, he was given antibiotics and IV fluids. Following initial resuscitation with IV fluids, he remains hypotensive. The ED physicians place a central venous catheter and begin infusing norepinephrine. Which of the following receptors are activated by norepinephrine?

• A. Alpha 1, Alpha 2, Beta 1, Beta 2
• B. Alpha 1, Alpha 2, Beta 1 (Correct Answer)
• C. Alpha 2
• D. Alpha 1, Beta 1, Dopamine 1
• E. Alpha 1, Beta 1

Sepsis Explanation: ***Alpha 1, Alpha 2, Beta 1*** - **Norepinephrine** primarily activates **alpha-1** (peripheral vasoconstriction), **alpha-2** (presynaptic inhibition and some vasoconstriction), and **beta-1** (increased heart rate and contractility) adrenergic receptors. - These are the **primary receptors** responsible for norepinephrine's clinical effects: vasoconstriction (alpha-1, alpha-2) and positive inotropic/chronotropic effects (beta-1). - This receptor profile makes norepinephrine an ideal **vasopressor** in septic shock, as seen in this patient. *Alpha 1, Alpha 2, Beta 1, Beta 2* - While **norepinephrine** does activate alpha-1, alpha-2, and beta-1 receptors, it has **negligible affinity for beta-2 receptors**. - **Epinephrine** (not norepinephrine) is the catecholamine with significant **beta-2 activity**, causing bronchodilation and vasodilation in skeletal muscle. - Including beta-2 is a common mistake when confusing norepinephrine with epinephrine. *Alpha 2* - This option is far too incomplete as **norepinephrine** has significant action on **alpha-1** and **beta-1** receptors, which are crucial for its vasoconstrictive and inotropic effects. - Activating only alpha-2 receptors would primarily lead to presynaptic inhibition and limited vasoconstriction, not the broad cardiovascular support required in septic shock. *Alpha 1, Beta 1, Dopamine 1* - While **norepinephrine** does activate **alpha-1** and **beta-1** receptors, it does **not** activate **dopamine 1 (D1) receptors**. - Only **dopamine** itself or specific **dopamine agonists** stimulate D1 receptors, leading to renal and mesenteric vasodilation. - This option incorrectly attributes dopaminergic activity to norepinephrine. *Alpha 1, Beta 1* - This option correctly identifies two of the main receptors activated by **norepinephrine**: alpha-1 (vasoconstriction) and beta-1 (positive inotropy and chronotropy). - However, it **omits alpha-2 receptors**, which norepinephrine also activates, contributing to both presynaptic feedback inhibition and additional vasoconstriction. - While not completely wrong, this is an incomplete answer.

Sepsis US Medical PG Question 5: A 38-year-old female presents to the emergency room with fevers, fatigue, and anorexia for over a month. Past medical history includes mild mitral valve prolapse. She underwent an uncomplicated tooth extraction approximately 6 weeks ago. Her vital signs include a temperature of 100.8 F, pulse of 83, blood pressure of 110/77, and SpO2 of 97% on room air. On exam, you note a grade III/VI holosystolic murmur at the apex radiating to the axilla as well as several red, painful nodules on her fingers. Which of the following is the next best course of action?

• A. Blood cultures are not needed. Start empiric antibiotics
• B. Start anticoagulation with heparin
• C. Consult cardiothoracic surgery for mitral valve replacement
• D. Obtain blood cultures x3 sites over 24 hours and start antibiotics after culture results are available
• E. Obtain blood cultures x3 sites over 1 hour and start empiric antibiotics (Correct Answer)

Sepsis Explanation: ***Obtain blood cultures x3 sites over 1 hour and start empiric antibiotics*** - The patient's presentation with **fever, fatigue, anorexia, new murmur, and painful finger nodules (Osler's nodes)** after a recent dental procedure strongly suggests **infective endocarditis**. Prompt initiation of **empiric antibiotics** after obtaining adequate blood cultures is crucial to improve outcomes and prevent further complications like septic emboli or valvular damage. - Obtaining **multiple blood cultures rapidly (e.g., three sets over 1 hour)** from different sites maximizes the chance of isolating the causative organism before antibiotics are given, enabling targeted therapy later, while minimizing delay to treatment. *Blood cultures are not needed. Start empiric antibiotics* - **Blood cultures are essential** for diagnosing infective endocarditis, identifying the causative organism, and guiding appropriate antibiotic therapy. Skipping blood cultures could lead to inappropriate antibiotic selection and treatment failure. - While empiric antibiotics are warranted, they should always be initiated **after blood cultures** have been drawn to avoid sterilizing the blood and making microbial identification difficult. *Start anticoagulation with heparin* - **Anticoagulation is generally contraindicated** in infective endocarditis due to the increased risk of hemorrhagic complications, especially in cases of septic emboli to the brain. - While patients with endocarditis can form vegetations that may embolize, the risks of **bleeding outweigh the benefits** of routine anticoagulation. *Consult cardiothoracic surgery for mitral valve replacement* - While **mitral valve prolapse** is a risk factor for endocarditis and severe valvular damage may eventually require surgery, primary management involves **antibiotic therapy**. - Surgical intervention is typically reserved for cases with **severe valvular regurgitation/stenosis leading to heart failure**, uncontrolled infection despite antibiotics, or recurrent emboli, and is not the immediate next step. *Obtain blood cultures x3 sites over 24 hours and start antibiotics after culture results are available* - Waiting for **24 hours to collect blood cultures** would significantly delay the initiation of antibiotics, which is dangerous in a potentially life-threatening infection like endocarditis. - Delaying antibiotics until **culture results are available** could take several days, leading to worsening infection, organ damage, and increased mortality. **Empiric antibiotics** must be started promptly after initial blood collection.

Sepsis US Medical PG Question 6: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

• A. "Does the diarrhea typically precede the constipation, or vice-versa?"
• B. "Is the diarrhea foul-smelling?"
• C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
• D. "Are the symptoms worse in the morning or at night?"
• E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)

Sepsis Explanation: ***Can you tell me more about the symptoms you have been experiencing?*** - This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis. - In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions. *Does the diarrhea typically precede the constipation, or vice-versa?* - While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience. - It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture. *Is the diarrhea foul-smelling?* - Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions. - However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed. *Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life* - Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time. - However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially. *Are the symptoms worse in the morning or at night?* - Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related. - This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.

Sepsis US Medical PG Question 7: A 39-year-old man comes to the physician for a follow-up examination. He was treated for a urinary tract infection with trimethoprim-sulfamethoxazole 2 months ago. He is paraplegic as a result of a burst lumbar fracture that occurred after a fall 5 years ago. He has hypertension and type 2 diabetes mellitus. Current medications include enalapril and metformin. He performs clean intermittent catheterization daily. He has smoked one pack of cigarettes daily for 19 years. His temperature is 37.1°C (98.8°F), pulse is 95/min, respirations are 14/min, and blood pressure is 120/80 mm Hg. He appears malnourished. Examination shows palpable pedal pulse. Multiple dilated tortuous veins are present over both lower extremities. There is a 2-cm wound surrounded by partial-thickness loss of skin and a pink wound bed over the right calcaneum. Neurologic examination shows paraparesis. His hemoglobin A1c is 6.5%, and fingerstick blood glucose concentration is 134 mg/dL. Which of the following is most likely to have prevented this patient's wound?

• A. Broad-spectrum antibiotic therapy
• B. Cessation of smoking
• C. Heparin therapy
• D. Topical antibiotic therapy
• E. Frequent position changes (Correct Answer)

Sepsis Explanation: ***Frequent position changes*** - This patient is paraplegic, which increases his risk for **pressure ulcers** due to prolonged immobility and sustained pressure on bony prominences like the calcaneum. - **Frequent repositioning** redistributes pressure, preventing skin breakdown and promoting circulation, thereby avoiding pressure injuries. *Broad-spectrum antibiotic therapy* - The wound is described as a **partial-thickness loss** with a pink wound bed, suggesting it's not primarily an infected wound requiring broad-spectrum antibiotics to prevent its formation. - Antibiotics are used to **treat existing infections**, not prevent pressure ulcers in a non-infected state. *Cessation of smoking* - While **smoking impairs wound healing** and overall vascular health, it is not the most direct or primary preventative measure for a pressure ulcer caused by immobility. - Smoking cessation would improve **long-term vascular health** and *ulcer healing*, but frequent position changes addresses the immediate cause of pressure. *Heparin therapy* - **Heparin** is an anticoagulant used to prevent **thrombosis** (blood clots), which is not the primary mechanism behind pressure ulcer formation. - While immobility can contribute to deep vein thrombosis, heparin would not prevent the **mechanical pressure-induced skin damage** that causes a calcaneal wound. *Topical antibiotic therapy* - Similar to systemic antibiotics, topical antibiotics are used for **treating localized infections** or preventing them in *open wounds*. - This wound is a result of pressure, and preventing its formation requires addressing the pressure itself, not merely applying antibiotics to the skin surface.

Sepsis US Medical PG Question 8: A 38-year-old previously healthy woman develops septic shock from necrotizing fasciitis of the lower extremity. Despite three debridements, broad-spectrum antibiotics (vancomycin, meropenem, clindamycin), IVIG, and aggressive critical care support, she develops refractory shock requiring norepinephrine 1.2 mcg/kg/min, vasopressin 0.04 units/min, and epinephrine 0.1 mcg/kg/min. Lactate is 15 mmol/L. Surgical team recommends hemipelvectomy as last option for source control. Family is devastated. ICU team notes SOFA score of 18. Synthesize an approach to management and decision-making.

• A. Transfer to ECMO center for consideration of VA-ECMO as bridge to hemipelvectomy
• B. Multidisciplinary meeting with surgery, ICU, palliative care, and family to discuss realistic outcomes, quality of life, and patient values before decision (Correct Answer)
• C. Continue medical management for 24 hours and proceed with hemipelvectomy only if shock improves
• D. Decline surgery based on futility given SOFA score >15 and initiate comfort care
• E. Proceed with hemipelvectomy immediately as only chance for survival with informed consent from family

Sepsis Explanation: ***Multidisciplinary meeting with surgery, ICU, palliative care, and family to discuss realistic outcomes, quality of life, and patient values before decision*** - In high-acuity cases with refractory shock and high **SOFA scores (>15)**, shared decision-making is essential to align surgical intervention with the patient’s **goals of care**. - This approach ensures that the **prognosis**, which carries a high risk of mortality and morbidity from **hemipelvectomy**, is transparently communicated by the entire medical team. *Transfer to ECMO center for consideration of VA-ECMO as bridge to hemipelvectomy* - **VA-ECMO** is generally not indicated in septic shock with refractory vasoplegia and severe multi-organ failure as it doesn't solve the **source control** issue. - The logistics and physiological stress of a transfer in the setting of **1.2 mcg/kg/min norepinephrine** would be highly unstable and likely fatal. *Continue medical management for 24 hours and proceed with hemipelvectomy only if shock improves* - Delaying source control in **necrotizing fasciitis** while shock is worsening usually leads to death, as medical management alone cannot overcome the focus of infection. - Waiting for improvement in the setting of a **lactate of 15 mmol/L** and triple vasopressors is unrealistic without definitive surgical intervention. *Decline surgery based on futility given SOFA score >15 and initiate comfort care* - While the **SOFA score** indicates a very high mortality risk, unilateral physician declaration of **medical futility** is ethically complex and can damage family trust. - Comfort care should remain a possibility, but first requires a thorough **interdisciplinary discussion** to ensure legal and ethical standards are met. *Proceed with hemipelvectomy immediately as only chance for survival with informed consent from family* - Performing such a **mutilating surgery** without a detailed discussion of the expected **quality of life** and long-term functional loss is poor surgical practice. - Immediate surgery without addressing the massive **operative mortality** risk ignores the patient's potential preference for a dignified death over a futile procedure.

Sepsis US Medical PG Question 9: A 52-year-old woman with septic shock from intra-abdominal infection undergoes emergency exploratory laparotomy for perforated diverticulitis with fecal peritonitis. Surgery reveals extensive contamination requiring damage control approach. Postoperatively, she requires norepinephrine 0.8 mcg/kg/min plus vasopressin 0.04 units/min, has lactate of 8.5 mmol/L, temperature 35.2°C, INR 2.8, pH 7.18, and base deficit -12. Planned return to OR is in 48 hours. Evaluate the priority interventions to optimize outcome.

• A. Immediate return to OR for definitive repair and anastomosis
• B. Start therapeutic hypothermia and delay reoperation until hemodynamically stable off vasopressors
• C. Initiate high-dose vasopressors to maintain MAP >75 mmHg and early enteral nutrition
• D. Administer massive transfusion protocol and emergency re-exploration within 6 hours
• E. Aggressive rewarming, correction of coagulopathy, ongoing resuscitation, and source control at planned reoperation (Correct Answer)

Sepsis Explanation: ***Aggressive rewarming, correction of coagulopathy, ongoing resuscitation, and source control at planned reoperation*** - This patient presents with the **lethal triad** (coagulopathy, acidosis, and hypothermia) in the setting of **septic shock**, necessitating physiologic stabilization before definitive surgery. - The gold standard for **damage control** is to stabilize the patient in the ICU by correcting **base deficit**, improving **lactate clearance**, and restoring normal temperature and coagulation parameters. *Immediate return to OR for definitive repair and anastomosis* - Attempting **definitive repair** or anastomosis in an unstable patient with fecal peritonitis and high-dose **vasopressor requirements** carries a prohibited risk of dehiscence and death. - Surgery should be limited to **staged re-intervention** only after the metabolic and physiologic insults have been partially reversed. *Start therapeutic hypothermia and delay reoperation until hemodynamically stable off vasopressors* - **Hypothermia** is a component of the lethal triad that worsens **coagulopathy** by inhibiting the clotting cascade; metabolic rewarming is required, not cooling. - While stability is the goal, waiting to be completely off vasopressors might dangerously delay **source control** if the infection is driving the shock. *Initiate high-dose vasopressors to maintain MAP >75 mmHg and early enteral nutrition* - Focus should be on **volume resuscitation** and reversing tissue hypoxia (lactate) rather than solely escalating vasopressors, which can cause **mesenteric ischemia**. - **Early enteral nutrition** is contraindicated in the immediate postoperative phase of an open abdomen with significant **hemodynamic instability** and high pressor requirements. *Administer massive transfusion protocol and emergency re-exploration within 6 hours* - **Massive transfusion protocol** is typically reserved for active, uncontrolled hemorrhage, whereas this patient primarily requires reversal of **septic shock** and metabolic derangements. - **Re-exploration within 6 hours** is too early for a damage control patient who has not yet been adequately rewarmed or had their **acidosis** corrected.

Sepsis US Medical PG Question 10: A 70-year-old man with recently diagnosed small cell lung cancer presents with septic shock from pneumonia. After initial resuscitation, he requires norepinephrine 0.6 mcg/kg/min and has a lactate of 7.8 mmol/L. His SOFA score is 14. The family requests 'everything be done,' but the patient had previously told his oncologist he would not want prolonged intensive care if his cancer prognosis was poor. Staging shows extensive-stage disease. The ICU team debates goals of care. What represents the most ethically appropriate approach to decision-making?

• A. Continue maximum therapy per family wishes as they are legal decision-makers
• B. Obtain ethics consultation to overrule family wishes based on futility
• C. Arrange urgent palliative care consultation and family meeting to discuss patient's previously expressed wishes and realistic prognosis (Correct Answer)
• D. Continue current therapy for 72 hours then reassess based on clinical trajectory
• E. Transition to comfort care based on poor oncologic prognosis and high SOFA score

Sepsis Explanation: ***Arrange urgent palliative care consultation and family meeting to discuss patient's previously expressed wishes and realistic prognosis*** - The most ethically sound approach is to use **substituted judgment**, which prioritizes the patient's **previously expressed wishes** about avoiding prolonged intensive care. - A **multidisciplinary family meeting** helps reconcile medical reality with patient values, ensuring informed **shared decision-making** rather than a unilateral or discordant approach. *Continue maximum therapy per family wishes as they are legal decision-makers* - While families are **surrogate decision-makers**, their role is to advocate for what the **patient would want**, not their own personal desires. - Blindly following "everything be done" ignores the patient's prior statement to his oncologist and risks providing **non-beneficial treatment**. *Obtain ethics consultation to overrule family wishes based on futility* - The term **medical futility** is often controversial; ethics consultations are designed to **mediate conflicts** rather than simply provide a mechanism to overrule families. - Unilateral decisions should only follow exhaustive attempts at **communication and mediation**, which have not yet occurred in this case. *Continue current therapy for 72 hours then reassess based on clinical trajectory* - A "time-limited trial" is a valid tool but fails to address the immediate ethical conflict regarding the **patient's autonomous refusal** of prolonged care. - This approach may unnecessarily prolong the dying process and ignore the **prognostic alignment** required between the oncology and ICU teams. *Transition to comfort care based on poor oncologic prognosis and high SOFA score* - Clinicians should not unilaterally transition to **comfort care** without discussing the patient's prognosis and values with the family/surrogates first. - While the **high SOFA score** and extensive cancer indicate a poor prognosis, the process must respect the legal and ethical requirements of **informed consent and withdrawal of care**.

Sepsis Flashcard 1 of 9

Question: Medi-_____ is state/federal assistance for people with limited income/resources

Answer: caid

Sepsis Flashcard 2 of 9

Question: Disinfestation of Scabies is achieved by laudering clothing and bedding in _____ water

Answer: hot

Sepsis Flashcard 3 of 9

Question: Which healthcare payment model involves physicians receiving a set amount per patient assigned to them per period of time? _____

Answer: Capitation

Sepsis Flashcard 4 of 9

Question: Is IDR a dynamic measure? _____

Answer: Yes

Sepsis Flashcard 5 of 9

Question: Which healthcare payment model involves patients paying for each individual service at a pre-determined, discounted rate?_____

Answer: Discounted fee-for-service

Sepsis Flashcard 6 of 9

Question: Which part of medicare provides hospital insurance and home hospice care? _____

Answer: Part A

Sepsis Flashcard 7 of 9

Question: tertiary prevention (epidemiology)

Answer: reduce morbidity and mortality (e.g. chemotherapy for cervical cancer)

Sepsis Flashcard 8 of 9

Question: List five common surrogate decision-makers (medical law) in order of decreasing priority.

Answer: spouse adult children parents adult siblings other relatives

Sepsis Flashcard 9 of 9

Question: What kind of gifts are acceptable? _____

Answer: Small ones

Extra Information:  https://onlinemeded.org?ref=anki