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* Fred - Hypotension
  mocha260 - 09/11/20 04:39
  A 23-year-old man is being evaluated in the intensive care unit because of steadily decreasing blood pressure since he was admitted 2 hours ago for treatment of septic shock caused by pneumonia. Medical history is remarkable for cystic fibrosis and severe obstructive lung disease. In the emergency department, the patient was intubated, had three peripheral intravenous catheters placed, and was treated empirically with broad-spectrum antibiotics, bronchodilators, a continuous infusion of propofol and fentanyl, and 4 L of 0.9% saline. Immediately after administration of fluids, the patient's pulse was 105/min and blood pressure was 100/50 mm Hg. The patient is 173 cm (5 ft 8 in) tall and weighs 59 kg (130 lb); BMI is 20 kg/m2
. Pulse is 135/min and blood pressure is 79/43 mm Hg.
Auscultation of the lungs discloses diffuse rhonchi and inspiratory crackles with low-pitched bilateral expiratory
wheezes. Cardiac examination discloses no murmurs, rubs, or gallops. Bedside ultrasonography of the abdomen
shows the inferior vena cava is 1.8 cm in diameter with minimum respirophasic collapsibility, and cardiac
ultrasonography shows that the left ventricular ejection fraction is approximately 0.65. Results of laboratory studies obtained on admission and now are shown:
On Admission Now Blood
WBC 21,000/mm3 19,000/mm3
Lactic acid 5.2 mg/dL 4.0 mg/dL

Which of the following is the most appropriate next step in management?
(A) Administer an additional 1-L bolus of 0.9% saline
(B) Administer intravenous hydrocortisone
(C) Administer intravenous voriconazole
(D) Begin a continuous infusion of norepinephrine
(E) Order CT scan of the head

Why not B??
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* Re:Fred - Hypotension
  mocha260 - 09/12/20 03:48

A - May not help
B - Hydrocortisone Rx = Addisons + Nonclassic CAH. --- adrenal insufficiency. so not the answer
C - Voriconazole = Rx = Aspergillus
E - CT done to r/o bleeding in head injury in stable pts this pt is unstable so can't do it.

D - Continuous Epi to maintain BP, but I was thinking continuous infusion might be too much . I don't know the clear protocol, but would appreciate more info.
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