A 65-year-old ICU patient on mechanical ventilation post-laparotomy for bowel perforation has a CVP of 6 mmHg and MAP of 60 mmHg. Fluid bolus fails to improve MAP. Lactate is 4.2 mmol/L. ScvO2 is 58%. According to Surviving Sepsis Campaign 2021 guidelines, the next intervention after ensuring adequate fluid resuscitation is:

• A Dobutamine infusion to increase cardiac output
• B Vasopressin as first-line vasopressor
• C Hydrocortisone 50 mg every 6 hours empirically
• D Norepinephrine as first-line vasopressor to target MAP ≥65 mmHg ✓

Explanation

Surviving Sepsis Campaign (SSC) 2021 guidelines recommend norepinephrine as the first-line vasopressor for septic shock to target MAP ≥65 mmHg. If MAP target is not achieved with norepinephrine alone, vasopressin (0.03-0.04 units/min) is added as a second agent. Epinephrine can be added as a third agent. Hydrocortisone is recommended only for patients with septic shock who require ongoing vasopressor therapy despite adequate resuscitation (200 mg/day IV continuous or 50 mg every 6 hours). Dobutamine is added when there is evidence of cardiac dysfunction/low cardiac output with elevated filling pressures, not as an initial step. ScvO2 <70% indicates inadequate oxygen delivery, supporting need for vasopressor and possibly inotrope optimization.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.