CCRN - Review Sepsis and MODS Questions and Answers 1 — Questions and Answers
Question 1: A 68-year-old patient is admitted from the emergency department with a diagnosis of community-acquired pneumonia. The patient has a temperature of 38.9°C, heart rate of 120 bpm, respiratory rate of 28/min, and a blood pressure of 88/50 mmHg. According to the Surviving Sepsis Campaign's Hour-1 Bundle, which of the following is a priority intervention?
- Administer broad-spectrum antibiotics. (Correct answer)
- Obtain a procalcitonin level.
- Insert a pulmonary artery catheter.
- Administer low-dose corticosteroids.
Correct answer: Administer broad-spectrum antibiotics.
The Surviving Sepsis Campaign Hour-1 Bundle emphasizes five critical, time-sensitive interventions: 1) Measure lactate level, 2) Obtain blood cultures, 3) Administer broad-spectrum antibiotics, 4) Begin rapid administration of crystalloid fluids for hypotension or high lactate, and 5) Apply vasopressors if hypotensive during or after fluid resuscitation. Administering antibiotics as soon as possible, ideally within the first hour of recognition, is a cornerstone of treatment to control the source of infection and has been shown to improve survival. The other options are not initial priorities in the first hour; procalcitonin is a diagnostic aid, a PA catheter is an advanced monitoring tool not used for initial resuscitation, and corticosteroids are considered later for refractory shock.
Question 2: A patient in the ICU is diagnosed with septic shock. The critical care nurse understands that the profound hypotension associated with this condition is primarily caused by which pathophysiological mechanism?
- Pathologic myocardial depression.
- A severe reduction in absolute intravascular volume.
- Intense systemic vasoconstriction.
- Massive peripheral vasodilation. (Correct answer)
Correct answer: Massive peripheral vasodilation.
Septic shock is a form of distributive shock. The pathophysiology involves a dysregulated host response to infection, leading to a massive release of inflammatory mediators like nitric oxide. These mediators cause profound systemic vasodilation, which dramatically decreases systemic vascular resistance (SVR) and leads to a relative hypovolemia and hypotension. While myocardial depression and fluid shifts from increased capillary permeability (leading to some volume loss) do occur, the primary and most defining hemodynamic alteration is massive vasodilation.
Question 3: A patient with a known infection has been receiving intravenous fluids for sepsis-induced hypotension. Despite receiving 30 mL/kg of crystalloid fluid, the patient's mean arterial pressure (MAP) is 60 mmHg and requires a norepinephrine infusion to maintain a MAP ≥ 65 mmHg. A repeat lactate level is 4.5 mmol/L. These findings are most indicative of which condition?
- Systemic Inflammatory Response Syndrome (SIRS).
- Septic Shock. (Correct answer)
- Sepsis.
- Multiple Organ Dysfunction Syndrome (MODS).
Correct answer: Septic Shock.
According to the Sepsis-3 consensus definitions, septic shock is a subset of sepsis characterized by profound circulatory, cellular, and metabolic abnormalities. The clinical criteria to identify septic shock are: 1) persistent hypotension requiring vasopressors to maintain a MAP of 65 mmHg or greater, AND 2) a serum lactate level greater than 2 mmol/L, despite adequate fluid resuscitation. This patient's clinical picture perfectly matches these criteria.
Question 4: A 55-year-old patient with septic shock has a mean arterial pressure (MAP) of 58 mmHg after receiving an adequate crystalloid fluid bolus. The physician orders a continuous vasopressor infusion. Which agent does the nurse anticipate administering as the first-line choice?
- Phenylephrine.
- Epinephrine.
- Norepinephrine. (Correct answer)
- Vasopressin.
Correct answer: Norepinephrine.
The Surviving Sepsis Campaign guidelines strongly recommend norepinephrine as the first-line vasopressor for septic shock. Its potent alpha-adrenergic effects cause vasoconstriction and increase systemic vascular resistance (SVR), directly counteracting the pathologic vasodilation of sepsis. It also has modest beta-1 adrenergic effects that support cardiac output. Vasopressin or epinephrine are typically considered second-line agents to be added if the patient is refractory to norepinephrine.
Question 5: A patient in the ICU for five days with severe sepsis from peritonitis now exhibits jaundice, a total bilirubin level of 4.5 mg/dL (77 µmol/L), and an INR of 1.8. These findings are most indicative of the onset of dysfunction in which organ system as part of MODS?
- Renal.
- Hematologic.
- Cardiovascular.
- Hepatic. (Correct answer)
Correct answer: Hepatic.
Multiple Organ Dysfunction Syndrome (MODS) is the progressive failure of two or more organ systems. The clinical signs of jaundice (icterus), a significantly elevated total bilirubin (normal <1.2 mg/dL), and a prolonged INR (reflecting impaired synthesis of clotting factors by the liver) are hallmark indicators of acute hepatic (liver) dysfunction.
Question 6: The critical care nurse is trending serial lactate levels in a patient undergoing resuscitation for septic shock. What is the primary clinical significance of a persistently elevated or rising lactate level in this setting?
- It reflects ongoing tissue hypoxia and anaerobic metabolism. (Correct answer)
- It is a direct marker of bacterial cell lysis.
- It indicates the development of acute kidney injury.
- It confirms the successful eradication of the infection.
Correct answer: It reflects ongoing tissue hypoxia and anaerobic metabolism.
In septic shock, impaired tissue perfusion from hypotension and microcirculatory dysfunction leads to cellular oxygen deprivation. Cells switch to anaerobic metabolism for energy, producing lactate as a byproduct. Therefore, a rising or persistently high lactate level is a key marker of ongoing tissue hypoperfusion and indicates that resuscitation efforts are not yet adequate to restore cellular oxygenation. Lactate clearance, in contrast, is associated with improved outcomes.
CCRN - Review Sepsis and MODS Questions and Answers 1
A 68-year-old patient is admitted from the emergency department with a diagnosis of community-acquired pneumonia.
The patient has a temperature of 38.9°C, heart rate of 120 bpm, respiratory rate of 28/min, and a blood pressure of 88/50 mmHg.
According to the Surviving Sepsis Campaign's Hour-1 Bundle, which of the following is a priority intervention?