Question of the Week

For June 9, 2020

An 82-year-old woman with a history of coronary artery disease, hypertension, and mild dementia presents to the emergency department from her assisted-living facility with one week of progressive dyspnea, cough, fatigue, and fevers.

She appears unwell and has a temperature of 38.9°C, a heart rate of 115 beats per minute, a blood pressure of 75/50 mm Hg, a respiratory rate of 32 breaths per minute, and an oxygen saturation of 93% while receiving 4 liters of oxygen via nasal cannula. She weighs 60 kg. She is edentulous and has focal crackles in the right lower lung field. Laboratory results are notable for leukocytosis, an elevated blood lactate level, and acute kidney injury. A chest radiograph reveals a dense opacity in the right lower lobe.

The patient is given a fluid bolus of 2 liters of lactated Ringer solution in addition to ceftriaxone and azithromycin, but her blood pressure remains low and her blood lactate level remains elevated. Ultrasound assessment of the inferior vena cava shows a dilated vessel and no collapse with inspiration. Bedside echocardiography reveals mildly depressed left ventricular systolic function.

The patient reports that she does not want intubation or cardiopulmonary resuscitation but will accept other interventions at this time.

What is the most appropriate next therapeutic intervention for this patient?

Administer an additional 30-mL/kg bolus of lactated Ringer solution
Start dobutamine to target a mean arterial pressure goal
Start norepinephrine to target a mean arterial pressure goal
Monitor central venous pressure (CVP), and administer normal saline to achieve a goal CVP
Initiate empiric anaerobic coverage with intravenous metronidazole

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