24 Hours Post-ICU Admission

Despite initial resuscitation, vasopressors, and ventilatory support, the patient’s condition continues to deteriorate.

Ventilator Settings (VCV):

• TV: 6 mL/kg IBW
• RR: 24/min
• FiO₂: 0.8
• PEEP: 10 cm H₂O
• Plateau pressure: 28 cm H₂O
• SpO₂: 89%
• ABG: pH 7.25 / PaCO₂ 38 / PaO₂ 58 / HCO₃⁻ 16

Current status:

• Noradrenaline: 0.35 mcg/kg/min
• Vasopressin: 0.04 U/min started
• MAP: 64 mmHg
• HR: 132 bpm
• Urine output: 80 mL in last 12 hrs
• GCS: E1VTM1 (on sedation)

Questions

1. What are the likely causes of this patient’s vasopressor-resistant shock at this stage? Name up to 3.
2. What are the indications for starting hydrocortisone now? What dose and schedule would you use?
3. What do the coagulation parameters suggest? How will you manage this?
4. Would you escalate antimicrobial therapy at this stage? Justify.
5. What additional source control or diagnostic steps would you now take?