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Septic shock — MRCEM SBA MCQ

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HardResuscitation and critical illnessSeptic shockMRCEM SBA

A 67-year-old man presents with fever, productive cough and a new right lower-zone infiltrate. His initial NEWS2 score is 10. Blood cultures have been taken and intravenous broad-spectrum antibiotics given. He has received four reassessed 250 mL boluses of Hartmann’s solution, but remains drowsy with a blood pressure of 76/42 mmHg, cool peripheries and a lactate of 5.1 mmol/L. He has no signs of pulmonary oedema. A senior emergency physician is at the bedside, the critical care team is immediately contactable, and a well-functioning peripheral cannula is visible and can be monitored. Central venous access has not been obtained. There is no treatment-escalation limitation. Which is the most appropriate next management plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Discuss peripheral vasopressors now with critical care and arrange monitored admission.

This patient has suspected sepsis with a high NEWS2 score and persistent hypotension and hypoperfusion despite antibiotics and 1 litre of crystalloid given in reassessed 250 mL boluses. NICE advises senior input when improvement remains inadequate after 1 litre, and discussion with critical care about both whether vasopressors are needed and whether they can be started peripherally when central access is unavailable. A visible, monitored peripheral line makes that route an option while ongoing organ support and monitored admission are arranged. ([nice.org.uk](https://www.nice.org.uk/guidance/ng253/chapter/Evaluating-risk)) A is tempting because he remains hypotensive and has no pulmonary oedema, but further fluid should not be the default response to failed initial resuscitation without senior reassessment. B reflects the conventional use of central access for vasopressors, but obtaining it need not precede discussion of a peripheral start. D uses an appropriate senior clinician, but NICE specifies the senior decision maker as the alternative when critical care is *not available*; here the team is immediately contactable. E offers another measure of perfusion, but the existing findings already warrant escalation, so a repeat result should not delay that discussion. If peripheral vasopressors are started, the cannula must remain visible and be monitored for extravasation under local policy. ([nice.org.uk](https://www.nice.org.uk/guidance/ng253/chapter/Managing-suspected-sepsis))

Reference: NICE NG253: Evaluating risk (19 November 2025) — https://www.nice.org.uk/guidance/ng253/chapter/Evaluating-risk NICE NG253: Managing suspected sepsis (19 November 2025) — https://www.nice.org.uk/guidance/ng253/chapter/Managing-suspected-sepsis NICE NG253: Managing suspected sepsis (19 November 2025) — https://www.nice.org.uk/guidance/ng253/chapter/Managing-suspected-sepsis