Hot case — vasopressor-dependent septic shock on day 2

Presentation

Candidate brief. Mrs K, 59, admitted 30 hours ago with rigors and right-upper-quadrant pain, diagnosed with ascending cholangitis and septic shock. She was intubated for work of breathing and a falling Glasgow Coma Scale, had an endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction and stent insertion 18 hours ago, and is now in the unit on noradrenaline at 0.4 mcg/kg/min, MAP 62 mmHg, lactate 3.6 mmol/L (down from 7.1), oliguric, and febrile at 38.6 °C. The bedside nurse reports the noradrenaline has crept up over the last three hours.

You have eight minutes to review the chart, examine the patient, and prepare a structured presentation before the examiner arrives.^[6]