Long case — septic shock, the fluid question and the rising lung water

Presentation

Candidate summary. Mrs K, 66, day 2 of septic shock from an obstructed, pyelonephritic urinary tract. She has received two litres of balanced crystalloid and is on noradrenaline at 0.3 mcg/kg/min, yet her mean arterial pressure is 62 mmHg, her lactate has risen from 2.4 to 4.1 mmol/L, her ScvO2 is 64%, and her oxygen requirement has climbed from 4 L/min to 10 L/min. The arterial line trace looks sharp and over-shooting, the central venous pressure reads 14 mmHg, and a focused echocardiogram this morning showed a small, hypercontractile left ventricle.

The haemodynamic questions are the case: is she still fluid-responsive (more fluid, or is she now drowning?), is the vasopressor dose adequate or is the vasoplegia deeper, and is the pump failing (is this now mixed shock)? Each question maps to a monitor and a decision.^[5]