# A 68-year-old male in the ICU is experiencing distributive shock secondary to sepsis. The patient's blood pressure is 78/45 mmHg, heart rate is 125 bpm, and urine output has decreased to 15 mL/hr over the past 2 hours. Which nursing intervention should be the priority?

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## 문제

A 68-year-old male in the ICU is experiencing distributive shock secondary to sepsis. The patient's blood pressure is 78/45 mmHg, heart rate is 125 bpm, and urine output has decreased to 15 mL/hr over the past 2 hours. Which nursing intervention should be the priority?

## 보기

1. Administer prescribed antibiotics immediately
2. Initiate vasopressor therapy as ordered **✔ 정답**
3. Increase the rate of IV fluid administration
4. Position the patient in Trendelenburg position

**정답: 2**

## 해설

In septic shock with persistent hypotension and oliguria despite fluids, vasopressor therapy is priority to restore perfusion pressure. Antibiotics and fluids are important but secondary if perfusion remains inadequate.

## 심화 해설

Understanding the Clinical Scenario

This patient is in the ICU with distributive shock secondary to sepsis. Distributive shock is characterized by profound vasodilation and increased capillary permeability, leading to a maldistribution of blood volume. The key assessment findings—blood pressure 78/45 mmHg (mean arterial pressure [MAP] of ~56 mmHg), heart rate 125 bpm, and urine output 15 mL/hr—paint a clear picture of hypoperfusion. The MAP is critically below the target of 65 mmHg, the tachycardia is a compensatory mechanism for the low stroke volume, and the oliguria indicates that vital organs, specifically the kidneys, are not being adequately perfused. The immediate threat to life is not the infection itself, but the life-threatening cardiovascular collapse it has triggered.

Analyzing the Priority Intervention

The Surviving Sepsis Campaign guidelines establish a clear, time-sensitive bundle of care. However, when a patient is in active shock with severe hypotension, the order of interventions is critical. The priority is to restore tissue perfusion to prevent irreversible organ damage and death.

*   Option 1: Administer prescribed antibiotics immediately. Antibiotic administration is a critical component of sepsis management and must be done as soon as possible, ideally within the first hour of recognition. However, in the context of this specific moment, the patient's immediate risk of death is from cardiovascular collapse, not from a delay in antibiotics of a few minutes. The role of the registered nurse (RN) in early management involves coordinating multiple tasks, but clinical prioritization dictates that stabilizing the airway, breathing, and circulation (ABCs) comes first [1]. While the RN will ensure antibiotics are administered promptly, it is not the very first priority when the patient is profoundly hypotensive.

*   Option 2: Initiate vasopressor therapy as ordered. This is the correct priority. The patient's distributive shock is driven by pathologic vasodilation. Fluid resuscitation is the initial step, but this patient is already in the ICU and has likely received or is receiving fluids, yet remains profoundly hypotensive with a MAP far below 65 mmHg. The clinical data (persistent hypotension and oliguria despite presumed initial fluid management) indicates that the patient is not fluid-responsive enough to wait, and vasopressors are now required to constrict the vasculature and achieve a life-sustaining perfusion pressure. The RN's role in the early management of sepsis includes the prompt initiation of prescribed therapies to restore hemodynamic stability, with vasopressors being the most direct intervention to counteract the vasodilation causing the immediate crisis [1].

Option 3: Increase the rate of IV fluid administration. Administering a 30 mL/kg crystalloid fluid bolus is a cornerstone of initial sepsis resuscitation. The RN is central to delivering this therapy [1]. However, the question asks for the priority intervention now*. The patient is already in the ICU, meaning fluid resuscitation has very likely been initiated. The persistent, severe hypotension (MAP ~56 mmHg) indicates that fluids alone are insufficient. Continuing to pour in large volumes of fluid without addressing the underlying vasoplegia can lead to harmful fluid overload without resolving the hypotension. The priority shifts from volume expansion to increasing vascular tone with a vasopressor.

*   Option 4: Position the patient in Trendelenburg position. The Trendelenburg position was historically used to promote venous return in hypotensive states. Current evidence-based practice does not support its use. It does not provide a sustained improvement in cardiac output or MAP, can impair respiratory mechanics, and may increase intracranial pressure. The passive leg raise is a validated, temporary maneuver to assess fluid responsiveness, but it is not a therapeutic intervention for sustained shock. This is not a priority action.

Connecting to the RN's Role in Sepsis Management

The scoping review by Lemoh et al. (2025) highlights that the RN's role in early sepsis management is a complex, multi-domain behavior set that goes beyond simple task execution [1]. It involves continuous clinical assessment, recognizing the trajectory of deterioration, and prioritizing interventions based on the patient's dynamic physiological state. In this scenario, the RN's assessment reveals a transition from a fluid-responsive state to a vasopressor-dependent state. The priority behavior is to recognize that the "Action" of initiating vasopressor therapy, for the "Target" of vascular tone, is the most time-critical intervention to prevent further decompensation [1]. The RN must understand that while antibiotics treat the source and fluids expand the volume, only vasopressors can immediately counteract the profound vasodilation that defines distributive shock and is causing the patient's critical hypotension right now.References (research sources)

- [1]Roles and responsibilities of registered nurses in the early recognition and management of sepsis in acute hospital settings: a scoping review.Research articleLemoh AY, Rashidzada Z, Krishnasamy M, Wilkinson A, Blackwood R, Rivalland A, Ierano C, Thursky KA, Guccione L. (2025) · DOI: 10.1136/bmjoq-2025-003485

## 임상 시나리오

Prioritizing Vasopressors in Fluid-Refractory Septic ShockWhen the MAP is critically low despite fluids, perfusion takes precedence
In distributive shock, persistent hypotension with a MAP below 65 mmHg despite initial fluid resuscitation indicates a need for immediate vasopressor support. The priority is to restore vascular tone and organ perfusion pressure.

First-line therapy is typically norepinephrine. Titrate the infusion to achieve a target MAP of at least 65 mmHg. Monitor for endpoints such as improved urine output and decreased lactate, not just blood pressure normalization.

CautionDo not delay vasopressor initiation to administer antibiotics or wait for additional fluid boluses in a patient with clear fluid-refractory shock. Concurrently, ensure antibiotics are given within the first hour, but hemodynamic stabilization is the immediate life-saving intervention.

## 핵심 개념

- **Distributive Shock** — A type of shock characterized by profound vasodilation and maldistribution of blood volume, commonly caused by sepsis, leading to functional hypovolemia and hypotension.
- **Mean Arterial Pressure (MAP)** — The average arterial pressure during a single cardiac cycle, calculated as (SBP + 2*DBP)/3. A target MAP of ≥65 mmHg is necessary for adequate organ perfusion.
- **Vasopressor Therapy** — Administration of medications like norepinephrine that cause vasoconstriction to increase systemic vascular resistance and blood pressure in shock states.
- **Surviving Sepsis Campaign** — An international initiative providing evidence-based guidelines for the management of sepsis and septic shock, emphasizing early recognition and bundled care.

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