Multiorgan dysfunction — Sepsis-3, resuscitation targets, support verdicts and the year after

Examiner prompts and model answers

Sepsis-3 in one breath, then apply it to him. Sepsis is life-threatening organ dysfunction from a dysregulated host response — SOFA rise of 2 or more, over 10% mortality — and shock adds vasopressor-dependent MAP 65-plus with lactate above 2, over 40% mortality; his day-2 multi-system failure with infection meets sepsis with MODS regardless of which of the 40 competing definitions you name, and qSOFA stays outside ICU.^[29]

His lactate is 4 and refill sluggish — which resuscitation target, and what does EGDT add? Run either target knowing ANDROMEDA's split: perfusion targeting did not cut 28-day death (34.9% versus 43.4%, HR 0.75, p=.06) but lowered 72-hour SOFA (5.6 versus 6.6, p=.045) without protocol harm — a mortality null with an organ signal.^[28] Add the EGDT brake: 13 trials and 5268 patients show benefit over usual care (RR 0.87) but loss to lactate-clearance guidance (RR 1.60), with the living review null overall (RR 0.85) and benefit confined above 35% control mortality — where your 3-hour goals are already met, 6-hour goals add nothing.^[55]

Which support drugs change his organ trajectory? Only steroids: hydrocortisone-plus-fludrocortisone cut 90-day death (43.0% versus 49.1%, RR 0.88) and added organ-failure-free days (14 versus 12) at a hyperglycaemia price.^[23] Bicarbonate does not move mortality in severe acidaemia with AKI (62.1% versus 61.7%) though it spares kidney replacement (35% versus 50%); vitamin C harms (44.5% versus 38.5%, RR 1.21, plus hypoglycaemia and anaphylaxis events); acetaminophen is a safe null on support-free days.^[22][24] His kidney sits at the centre of every crosstalk — lung, heart, liver, gut, brain via IL-6/TNF-alpha inflammation — so protect it to protect them.^[10]

What do you tell his wife about the year? That survival starts a second illness: Swedish 56% versus 26% dead with hazard 3.0 falling only to 1.6 beyond five years, two-thirds of survivors locked in hyperinflammation-plus-immunosuppression with 1-year death odds 8.26 — so he leaves with MoCA/HADS/IES-R/walk/EQ-5D screening from 2-4 weeks and a named follow-up owner.^[61][63]