A septic shock patient has received adequate fluids and norepinephrine, with MAP maintained at 72 mmHg and urine output improving. Central venous oximetry shows ScvO2 of 55 percent and haematocrit is 33 percent. According to early goal-directed therapy principles, the next intervention is:

• A Start dobutamine infusion to increase oxygen delivery ✓
• B Transfuse packed red cells to raise haematocrit above 30 percent
• C Increase norepinephrine further to raise MAP to 85 mmHg
• D Add intravenous sodium bicarbonate for lactic acidosis

Explanation

In the Rivers protocol, a persistently low ScvO2 below 70 percent after fluids and vasopressors signals inadequate oxygen delivery. If the haematocrit is already at or above 30 percent, transfusion adds nothing and dobutamine is the next step to augment stroke volume and oxygen delivery. Pushing MAP higher with more norepinephrine increases afterload without improving tissue extraction, and bicarbonate therapy in lactic acidosis has shown no survival benefit and may impair oxygen unloading.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.