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
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.