A 70 kg critically ill post-operative patient develops septic shock. Fluid resuscitation with 30 mL/kg crystalloid (2,100 mL) has been administered. CVP is 12 mmHg, MAP remains 58 mmHg, lactate is 4.2 mmol/L, ScvO2 is 68%. What is the next step per SSC (Surviving Sepsis Campaign) 2021 bundle?

• A Continue IV fluid boluses until CVP reaches 15–18 mmHg
• B Transfuse packed red blood cells to Hb >10 g/dL to raise ScvO2
• C Give 200 mL albumin 20% to expand intravascular volume
• D Start norepinephrine to achieve MAP ≥65 mmHg and obtain cultures before further antibiotics ✓

Explanation

SSC 2021 1-hour bundle: once initial fluid resuscitation (30 mL/kg crystalloid) fails to restore hemodynamics, norepinephrine should be started to maintain MAP ≥65 mmHg — it is the first-line vasopressor in septic shock. CVP-guided fluid therapy has been abandoned by SSC guidelines; further fluid challenges based on CVP alone risk fluid overload. ScvO2 targets (>70%) are no longer a mandatory bundle element per SSC 2021. Transfusion is only indicated for Hb <7 g/dL (not to arbitrarily raise ScvO2). Albumin is considered adjunctive when large-volume crystalloid is required but is not the primary next step.

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

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Written and medically reviewed by the StethoPrep medical team.