A 76-year-old woman was found in her home with a decreased level of responsiveness. The patient's daughter last saw her yesterday morning, and the patient can provide no further information. Vital signs: rectal temperature 96.6°F, heart rate 120/min, respiratory rate 26/min, blood pressure 84/44 mm Hg, oxygen saturation 94% on room air. Your examination is significant for signs of dehydration and a diminished mental status. Laboratory values reveal WBC of 18.2 with 10% band forms, hemoglobin 9.6 g, hematocrit 28.8%, platelets 120,000, sodium 128 mEq/L, potassium 3.4 mEq/L, BUN 64 mg/dL, and creatinine of 2.8 mg/dL. Urinalysis is consistent with a urinary tract infection. Which of the following statements regarding this patient's condition is true?
The patient may benefit from cortisol administration.
Fluid resuscitation should be limited due to her decreased oxygen saturation and concerns for precipitating pulmonary edema.
A serum lactate is of limited value.
The patient should be transfused with packed red blood cells (PRBC) until her hematocrit is greater than 50%.
A CVP less than 8 mm Hg is a good prognostic sign.
Sepsis is defined as the presence of an infection and evidence of a systemic inflammatory response (SIRS) manifested by abnormalities in vital signs (temperature, pulse rate, and respiratory rate) or laboratory values (leukocytosis or bandemia). A complex series of pathophysiologic events are responsible for the transition from infection to SIRS to sepsis to septic shock. Increasing evidence seems to show that early goal-directed therapy (EGDT) aimed at reversing tissue hypoxia and decreasing tissue hypoperfusion combined with timely, broad-spectrum antibiotic administration leads to improved morbidity and mortality. Septic patients should undergo central venous (preferably internal jugular or subclavian placement) and arterial catheterization and should have central venous pressure (CVP), mean arterial pressure (MAP), and central venous oxygen sat (SvO2) continually monitored and reassessed. Fluids should be given to keep CVP greater than 8 mm Hg. Vasopressors should be titrated to keep the MAP greater than 65 mm Hg. Transfusions of PRBC should be given to keep the hematocrit greater than 30%. Although the routine use of corticosteroids in sepsis has not yet been established, the use of supplemental corticosteroids in sepsis is common and may help correct underlying adrenal insufficiency. However, a hormone stimulation test or baseline cortisol level should be performed first.