A 65-year-old man with septic shock following Hartmann's reversal surgery is on mechanical ventilation. After 3 litres of fluid resuscitation, CVP is 12 mmHg, MAP is still 58 mmHg, and lactate is 5 mmol/L at 6 hours. According to the Surviving Sepsis Campaign 2021 guidelines, which parameter best guides further fluid administration?
- A Central venous pressure (CVP) target > 12 mmHg indicates adequate fluid loading; no more fluid needed
- B Passive leg raise (PLR) test: a ≥ 10% increase in cardiac output/pulse pressure confirms fluid responsiveness before giving additional bolus ✓
- C Urine output < 0.5 mL/kg/hr for 2 hours is the most reliable indicator for further fluid resuscitation
- D A pulmonary artery catheter (PAC) should be inserted to accurately measure PCWP before additional fluids
Explanation
Surviving Sepsis Campaign 2021 recommends using dynamic measures of fluid responsiveness (not static measures like CVP) to guide resuscitation. The passive leg raise (PLR) test is a reversible preload challenge: raising legs 45° for 1 minute auto-transfuses ~300 mL of venous blood; if cardiac output (or pulse pressure as surrogate) increases ≥ 10%, the patient is fluid-responsive and will benefit from a fluid bolus. CVP is a poor predictor of fluid responsiveness and should not guide therapy alone. PAC is not routinely recommended. Urine output is too non-specific and delayed. PLR combined with cardiac output monitoring (e.g., PiCCO, esophageal Doppler, or arterial pulse pressure variation) is the recommended approach.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.