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.
Answer and interpretation
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.
- Hypovolaemia or hidden bleeding E.g. From surgical site/ peptic ulcer, “third space” losses (e.g. ascites from peritonitis)
- Undiagnosed or new “obstructive shock”: Tension pneumothorax / Pericardial effusion / gas trapping (auto PEEP) / pleural effusions / pulmonary emboli / Severe Intra abdominal hypertension
- Cardiogenic: Dysrhythmia e.g. SVT, junctional rhythm etc., New myocardial ischaemia, New/ undiagnosed cardiac valve pathology
- Severe adrenal / pituitary / thyroid dysfunction.
- Drug reaction / anaphylaxis
- 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 – e.g. 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 (e.g. dissection or aorto- occlusive disease: femoral arterial line)
- Anti hypertensive drugs taken as part of patients usual medications