Acute Care Nurse Practitioner Sepsis and Septic Shock Management 2 — Questions and Answers
Question 1: What is the recommended initial fluid resuscitation volume for sepsis-induced tissue hypoperfusion according to Surviving Sepsis Campaign guidelines?
- 10 mL/kg of isotonic crystalloid administered over 30 minutes
- 30 mL/kg of isotonic crystalloid administered within 3 hours (Correct answer)
- 1 L of 5% albumin solution administered over 1 hour
- 500 mL of normal saline followed by immediate reassessment before further fluids
Correct answer: 30 mL/kg of isotonic crystalloid administered within 3 hours
The SSC guidelines recommend at least 30 mL/kg of isotonic crystalloid (normal saline or lactated Ringer's) within 3 hours for sepsis-induced hypoperfusion or hypotension.
Question 2: Which vasopressor is recommended as first-line therapy for septic shock to maintain mean arterial pressure ≥ 65 mmHg?
- Dopamine at 5-20 mcg/kg/min
- Epinephrine at 0.01-0.5 mcg/kg/min
- Norepinephrine at 0.01-3 mcg/kg/min (Correct answer)
- Vasopressin at 0.03-0.04 units/min
Correct answer: Norepinephrine at 0.01-3 mcg/kg/min
Norepinephrine is the first-line vasopressor for septic shock due to its potent alpha-1 adrenergic vasoconstriction with modest beta-1 effects, reliably raising MAP with less tachycardia than dopamine.
Question 3: Which empiric antibiotic regimen is most appropriate for a patient with community-acquired septic shock of unknown source?
- Vancomycin plus cefazolin for narrow-spectrum gram-positive coverage
- Vancomycin plus piperacillin-tazobactam or meropenem, with atypical coverage if pneumonia is suspected (Correct answer)
- Azithromycin plus amoxicillin-clavulanate as oral equivalent if hemodynamically stable
- Ciprofloxacin 400 mg IV q8h monotherapy for broad enteric gram-negative coverage
Correct answer: Vancomycin plus piperacillin-tazobactam or meropenem, with atypical coverage if pneumonia is suspected
Empiric therapy for septic shock requires broad-spectrum coverage including MRSA (vancomycin) and gram-negative organisms (pip-tazo or carbapenem) until cultures guide de-escalation.
Question 4: A patient in septic shock remains hypotensive on norepinephrine 0.25 mcg/kg/min with MAP of 58 mmHg. What is the most appropriate next step for vasopressor management?
- Escalate norepinephrine to the maximum dose of 3 mcg/kg/min before adding any second agent
- Add vasopressin 0.03-0.04 units/min as a norepinephrine-sparing adjunct to raise MAP (Correct answer)
- Switch from norepinephrine to dopamine as second-line monotherapy
- Add phenylephrine 100 mcg/min to augment alpha-adrenergic vasoconstriction
Correct answer: Add vasopressin 0.03-0.04 units/min as a norepinephrine-sparing adjunct to raise MAP
Vasopressin at 0.03-0.04 units/min is recommended as an adjunct to norepinephrine in refractory septic shock, acting on V1 receptors independently of catecholamine pathways to reduce norepinephrine requirements.
Question 5: Under which clinical circumstances should intravenous hydrocortisone be administered in septic shock?
- All patients with septic shock should receive hydrocortisone 200 mg/day prophylactically
- When septic shock remains refractory to adequate fluid resuscitation and vasopressor therapy (Correct answer)
- Only when confirmed primary adrenal insufficiency is documented by cosyntropin (ACTH) stimulation testing
- When the patient's core temperature exceeds 39.5°C and blood cultures remain negative
Correct answer: When septic shock remains refractory to adequate fluid resuscitation and vasopressor therapy
Hydrocortisone 200 mg/day IV is recommended for septic shock not adequately stabilized with fluid resuscitation and vasopressors, not as routine first-line therapy for all sepsis patients.
Question 6: According to current Surviving Sepsis Campaign guidelines, packed red blood cells should be transfused in septic shock when hemoglobin falls below:
- 10 g/dL in all patients with septic shock to optimize oxygen delivery
- 7 g/dL in adults without active myocardial ischemia, severe hypoxemia, or acute hemorrhage (Correct answer)
- 8 g/dL when concurrent serum lactate is greater than 2 mmol/L
- 9 g/dL in all patients requiring mechanical ventilation
Correct answer: 7 g/dL in adults without active myocardial ischemia, severe hypoxemia, or acute hemorrhage
SSC recommends a restrictive transfusion strategy with a threshold of 7 g/dL for most adult patients with sepsis, reserving higher thresholds for those with myocardial ischemia or active hemorrhage.
Question 7: What is the recommended blood glucose target for patients in septic shock receiving insulin therapy?
- Tight glycemic control targeting 80-110 mg/dL to minimize infectious complications
- Blood glucose ≤ 180 mg/dL using a validated protocol with frequent glucose monitoring (Correct answer)
- Permissive hyperglycemia with a target of 140-200 mg/dL to reduce hypoglycemia risk
- Blood glucose < 150 mg/dL with no specified lower limit for hypoglycemia avoidance
Correct answer: Blood glucose ≤ 180 mg/dL using a validated protocol with frequent glucose monitoring
SSC recommends insulin therapy targeting glucose ≤180 mg/dL; the NICE-SUGAR trial demonstrated that tight control targeting 80-110 mg/dL increased mortality compared with the conventional target.
Acute Care Nurse Practitioner Sepsis and Septic Shock Management 2
What is the recommended initial fluid resuscitation volume for sepsis-induced tissue hypoperfusion according to Surviving Sepsis Campaign guidelines?