Q1. What are the likely causes of this patient’s vasopressor-resistant shock at this stage? Name up to 3.

1. Uncontrolled sepsis – ongoing peritoneal contamination (cloudy drain, ↑PCT, ↑WBC)
2. Relative adrenal insufficiency – catecholamine-refractory shock
3. Evolving DIC – impaired microcirculation and capillary leak (↑INR, ↓platelet, ↓fibrinogen)

Examiner Commentary:
They expect a broad systems view, not just blaming “sepsis.” Include endocrine and hematological causes when pressor-resistant.

Q2. What are the indications for starting hydrocortisone now? What dose and schedule would you use?

Indications: Persistent hypotension despite adequate fluids and 2 vasopressors (noradrenaline + vasopressin) → suggests refractory septic shock
Dose: Hydrocortisone 50 mg IV Q6H or 200 mg/day continuous infusion

Examiner Commentary:
Use guideline-based logic (e.g., Surviving Sepsis Campaign). Always give dose and frequency.

Q3. What do the coagulation parameters suggest? How will you manage this?

Suggestive of DIC:

• ↑INR, ↓platelets, ↓fibrinogen, high D-dimer, deranged TEG
  Management:
• FFP to correct INR (>1.5), platelets if <50k, cryoprecipitate if fibrinogen <1.5 g/L
• Vitamin K 10 mg IV once
• Avoid invasive procedures; monitor for bleeding
• Treat underlying sepsis

Examiner Commentary:
Don’t just label “DIC” — you must specify how you’ll manage it practically, especially thresholds for blood products.

Q4. Would you escalate antimicrobial therapy at this stage? Justify.

Yes – clinical deterioration, rising PCT, cloudy drain, and new organ dysfunction → possible uncontrolled or secondary intra-abdominal infection (e.g., fungal, ESBL, or nosocomial).

• Consider escalation to meropenem ± antifungal (e.g., echinocandin) depending on prior coverage
• Send cultures: drain fluid, blood, urine

Examiner Commentary:
Justification is key — don’t say “escalate” without reasoning. Culture data, clinical progression, and markers like PCT should guide your thought process.

Q5. What additional source control or diagnostic steps would you now take?

1. Urgent surgical re-evaluation or imaging (CECT abdomen) to assess for missed collections, anastomotic leak, or abscess
2. Drain fluid analysis and culture
3. Consider percutaneous drainage if localized collection present

Examiner Commentary:
EDIC values source control thinking as highly as antibiotics. Reassessing peritoneal source = essential at this stage.