Review Question - QID 204111

This patient with meningococcal meningitis has received a vasopressor for blood pressure support in the setting of septic shock. A known side effect of vasopressors is digital ischemia secondary to vasospasm.

Norepinephrine raises blood pressure primarily by increasing vascular tone through alpha-adrenergic receptor activation. It activates both alpha-1 and alpha-2 adrenergic receptors. Norepinephrine will also increase cardiac output through increased chronotropy (increase in heart rate), though this is to a lesser extent than its direct effects on vascular tone.

Russel et al. evaluated the effects of vasopressin as an adjunct to norepinephrine in patients with septic shock. The addition of low dose vasopressin did not reduce mortality overall, but did allow lower doses of norepinephrine to be used.

Bamberger summarizes the diagnosis, initial management, and prevention of meningitis. He notes that prompt initiation of empiric antimicrobial therapy based on age and risk factors is the most important step in management of bacterial meningitis. Among adults in the US and other developed countries, the mortality rate from bacterial meningitis is 21%.

In the 2013 Update to the Surviving Sepsis Campaign Guidelines, Dellinger et al. discuss the initial choice of vasopressor for hypotension or tissue hypoperfusion that persists despite adequate volume resuscitation. Norepinephrine is the standard first-line pressor for central administration.

Illustration A contains a flow diagram of the sepsis screening protocol from the Surviving Sepsis Campaign.

Incorrect Answers:
Answer 1: A common gas-producing microorganism is Clostridium perfringens, a gram-positive, rod-shaped, anaerobe. These infections are usually due to a non-sterile field surgery or severe projectile wounds contaminated by soil. This is not a likely cause of this patient's digital ischemia.
Answer 2: Neisseria meningitidis can cause meningococcal septicaemia, presenting with a purpuric, non-blanching rash. In these cases the classical symptoms of meningitis are usually not present, and this patient's skin findings are more suggestive of diffuse hypoperfusion rather than purpura.
Answer 3: Digital ischemia can result from poor cardiac output, however patients with septic shock often have high cardiac output, and peripheral vasoconstriction from norepinephrine is more likely in this previously healthy young person.
Answer 5: This describes the hypothesized cause of Stevens-Johnson syndrome, a life-threatening hypersensitivity reaction that results in a separation of the epidermis from the dermis. These lesions generally begin on the oral mucosa.