Septic Shock — ABEM Board MCQ

Correct answer: A — Administer 30 mL/kg IV crystalloid promptly

The correct answer is A, administer 30 mL/kg IV crystalloid promptly. This patient has septic shock with hypotension (MAP 55 mm Hg) and a lactate of 5.2 mmol/L, both of which meet the Surviving Sepsis Campaign Hour-1 Bundle threshold for immediate 30 mL/kg crystalloid resuscitation. Fluid resuscitation, obtaining cultures before antibiotics, and starting broad-spectrum antibiotics within the first hour occur concurrently, not sequentially, and prompt fluids are essential to restore perfusion while vasopressors are prepared if hypotension persists. This is a strong recommendation because uncorrected hypoperfusion drives ongoing tissue hypoxia, organ dysfunction, and mortality, and early aggressive fluid administration has been shown to improve outcomes compared with delayed resuscitation. Why the other options are wrong: B. Delay fluids until vasopressors are started: This inverts the resuscitation sequence; crystalloid should begin immediately and vasopressors are added if MAP remains below 65 mm Hg despite adequate fluids, not before fluids are given. C. Give low-dose dopamine for renal perfusion: Renal-dose dopamine has no protective effect on renal function or outcomes in sepsis and is no longer recommended by current guidelines; norepinephrine is the first-line vasopressor when needed, not low-dose dopamine. D. Hold antibiotics until source is confirmed: Antibiotics should be given within one hour of recognition of septic shock after cultures are drawn; withholding therapy pending source confirmation delays treatment and increases mortality risk. E. Restrict fluids due to risk of pulmonary edema: Fluid restriction is inappropriate during initial resuscitation of septic shock with hypotension and hyperlactatemia; conservative fluid strategies apply later in management, not during the first hour when the patient is under-resuscitated. Key point: Hypotension (MAP under 65 mm Hg) or lactate 4 mmol/L or higher triggers immediate 30 mL/kg crystalloid within the Hour-1 Bundle, concurrent with cultures and early antibiotics.

Reference: Surviving Sepsis Campaign, Hour-1 Bundle: Levy MM et al., 'The Surviving Sepsis Campaign Bundle: 2018 Update' and 2021 International Guidelines for Management of Sepsis and Septic Shock, Critical Care Medicine 2021; Hour-1 Bundle recommends 30 mL/kg IV crystalloid for hypotension or lactate >=4 mmol/L, https://pmc.ncbi.nlm.nih.gov/articles/PMC7963440/