CC PA here. I see these cases everyday. Just a couple of pearls for you:
this definitely wreaks of sepsis so definitely some fluids and ABX are warranted. However, Without better history and labs it’s hard to get a true sense of the differential. It sounds like she may have some comordities/chromic health issues (ESRD???) which would be helpful to know. Overdose? DKA? HHS? ACS unlikely without some EKG findings but agree that cardiac enzymes will be elevated regardless in a renal patient
With renal failure patients you should be resuscitating with balanced crystalloid as opposed to saline (SALT-ED and SMART trials) Also this patient needs dialysis ASAP. Call your local nephrologist!! A tip for obtaining central access in acute renal failure-put the Cvc in the left IJ or the femoral. Patient will likely need temp HD catheter placement and the catheters have better flow when placed in the right IJ.
also, I would have started this patient on pressor immediately when fluids werent doing much. “Filling the tank” only works when the tank isn’t leaking out everything you put in it into the interstitium. Give some fluid (30 cc/kg is COMPLETELY arbitrary and based no real data....also use ideal body weight) but if it’s isnt working start pressors! Pressors are not dangerous! Don’t keep pounding them with fluids. You can run pressor safely through a peripheral Line until you get central access so don’t delay. norepinephrine firstline followed by vasopressin and solucortef if she requires >15mcg/min norepinephrine.
as far as volume assessment, she is likely dry based on your description. However, looking at the IVC with US is essentially a coin flip when evaluating volume status. There are a ton of confounding physiologic variables that muddy your assessment. Also, a CVP of 2 is not abnormal and again is absolutely useless in managing shock. A more valuable use of the ultrasound would be to look at the heart, kidneys, lungs and do a quick fast exam (rule out uremic pericarditis with effusion lol ?)
Procalcitonin is useless in renal patients in my experience. Also, is it going to change your management of this patient?
Agree with check a CK. Anyone found down needs a CK checked
Cultures only grow something out ~1/3 of the time so don’t stop ABX based on that. Also, qSOFA is garbage. It’s not very sensitive and wasn’t validated. The sepsis guidelines in general are useless.
Septic patients often have a mixed shock shock picture due to vasoplegia as well a cardiogenic component due septic cardiomyopathy...more common than you’d think!
a final thought on her airway. I would’ve have intubated this patient. If her pH is truly 6.9 and she’s not breathing hard or has a normal pCO2 that’s means she’s crapped out. Also when patients are in extremis work of breathing can use a significant chunk of your cardiac output. Alleviate that burden!! If you do decide to intubate, have pressors and fluids going when giving induction agents or you can write “death by glidescope” on her death certificate!
overall is an interesting case. Definitely enjoy managing these patients.