M.K., a 56-year-old man, was admitted 5 days ago with a chief complaint of acute abdominal pain of 3 days’ duration associated with bloody diarrhea, fever, tachypnea, and hypotension. The diagnosis was superior mesenteric artery occlusion with necrotic bowel and he subsequently underwent surgery to remove necrotic bowel tissue. During postoperative days 1 through 4, his SCr increased to 1.5 mg/dL, and he could not be weaned completely from ventilatory support. Vital signs were stable. Antibiotic therapy included ciprofloxacin and metronidazole in appropriate doses. M.K. has a history of coronary artery disease with stable angina pectoris that has been treated with lisinopril, simvastatin, and nitroglycerin. He had no other medical problems before admission. On the morning of postoperative day 5, M.K. has a spiking fever to 39.4?C. Physical findings include a BP of 98/60 mm Hg, pulse 128 beats/minute, and an RR of 28 breaths/minute. His urine output has dropped to 25 mL/ hour, and bowel sounds are absent. The chest radiograph shows an enlarged heart with bilateral pulmonary infiltrates and right lower lobe atelectasis. M.K. has become confused and disoriented. ABG on an inspiratory oxygen concentration of 40% are as follows: PaO2, 76 mm Hg PaCO2, 34 mm Hg HCO3 ?, 15 mEq/L pH, 7.31 M.K. has had increased bronchial secretions for the past 2 days. Pertinent laboratory values are as follows: SCr, 1.8 mg/dL BUN, 32 mg/dL WBC count, 18,000 cells/?L Urine, sputum, and blood samples are sent for culture and sensitivity. A fluid bolus of 1,000 mL of normal saline solution is given. Arterial and pulmonary artery catheters are inserted, revealing the following hemodynamic profile: BP (S/D/M), 90/50/63 mm Hg Pulse, 122 beats/minute CO, 6 L/minute CI, 3.5 L/minute/m2 PCWP, 12 mm Hg SVR, 720 dyne · s · cm–5 M.K. weighs 70 kg and has a body surface area of 1.7 m2. What hemodynamic and clinical features of M.K. are consistent with septic shock?
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