Mr. Ranjit: Fever, Confusion and Falling Pressure

• Move immediately to a resuscitation bay; apply continuous ECG, SpO₂ and non-invasive BP monitoring; assess airway and work of breathing.
• Give supplemental oxygen targeting SpO₂ about 92–96% unless there is a known chronic hypercapnic state; obtain ABG/VBG promptly if respiratory failure is suspected.
• Establish two large-bore IV lines. Send cultures without delaying therapy. Start balanced crystalloid in aliquots with frequent reassessment; in sepsis-induced hypoperfusion/shock, current SSC guidance supports at least 30 mL/kg within the first 3 hours while individualising to cardiac/renal status.
• Start broad-spectrum IV antibiotics immediately, ideally within 1 hour in septic shock, chosen for local CAP resistance, recent healthcare exposure and aspiration/MRSA/Pseudomonas risk.
• If MAP remains below ~65 mmHg despite initial fluid, start norepinephrine early rather than waiting for large fluid volumes; peripheral initiation through a well-sited proximal vein is acceptable while definitive access is arranged.

• CBC, electrolytes, urea/creatinine, glucose, LFT, coagulation profile, lactate, ABG, CRP/procalcitonin if locally useful, blood cultures ×2 before antibiotics when this does not delay treatment.
• Portable chest radiograph; bedside lung and cardiac ultrasound to assess consolidation, B-lines, LV/RV function and fluid responsiveness.
• Sputum Gram stain/culture if an adequate sample is available; urinary pneumococcal/Legionella antigen when epidemiologically appropriate; respiratory viral PCR during circulating outbreaks.
• Urinalysis and strict hourly urine output; baseline ECG and troponin if shock-associated myocardial injury is possible.

• Reassess perfusion after each intervention: mental status, capillary refill, skin temperature, urine output, lactate trend and dynamic fluid-responsiveness measures rather than static CVP alone.
• If norepinephrine requirement rises, add vasopressin rather than escalating norepinephrine indefinitely; consider epinephrine if shock remains refractory.
• Identify and treat complications such as empyema, lung abscess, aspiration or a second infectious source. Drain pleural infection promptly when indicated.
• De-escalate antibiotics once microbiology and clinical response clarify the pathogen; avoid unnecessarily prolonged courses after adequate source control.

• At 2 hours: after 1.5 L balanced crystalloid, MAP is 61 mmHg, lactate 5.2 mmol/L, urine output 10 mL/h. Norepinephrine is started and titrated to MAP ~65 mmHg.
• At 6 hours: MAP 68 mmHg on norepinephrine 0.14 µg/kg/min, lactate falls to 3.4 mmol/L, but oxygenation worsens: PaO₂/FiO₂ ≈160 with bilateral opacities and no dominant cardiogenic explanation.
• The working problem has evolved from isolated pneumonia to septic shock complicated by moderate ARDS; fluid strategy should now become conservative once shock is stabilised.

• Use lung-protective invasive ventilation if intubation is required: tidal volume ~6 mL/kg predicted body weight, plateau pressure <30 cmH₂O, and appropriate PEEP/FiO₂ titration.
• For moderate–severe ARDS, early prone positioning for prolonged sessions (commonly ≥16 h/day) should be considered when PaO₂/FiO₂ remains <150 despite optimisation.
• Avoid routine continuous neuromuscular blockade; use short boluses or a limited infusion only when severe ventilator dyssynchrony or proning demands it.
• Consider IV corticosteroids in vasopressor-dependent septic shock according to current practice, commonly hydrocortisone 200 mg/day in divided doses or infusion when shock remains refractory.
• Escalate to VV-ECMO referral in severe potentially reversible ARDS failing optimal ventilation/proning in an experienced centre.

Septic shock secondary to severe community-acquired pneumonia, complicated by acute hypoxaemic respiratory failure/ARDS.

• Continue haemodynamic support with norepinephrine first line, vasopressin as adjunct if needed, and repeated perfusion reassessment.
• Continue targeted antimicrobial therapy with daily review for narrowing and duration.
• Adopt conservative fluid balance after shock reversal; prevent VTE, stress-related mucosal injury when indicated, pressure injuries and ICU delirium.
• Begin enteral nutrition early when haemodynamically stable; assess readiness for spontaneous awakening/breathing trials once improving.

• Sepsis is a clinical emergency: antibiotics, haemodynamic support and source control proceed in parallel.
• In 2026 SSC guidance, balanced crystalloids are favoured over normal saline for most septic patients and an initial MAP target around 65 mmHg remains standard.
• After initial resuscitation, more fluid is not automatically better; use dynamic reassessment.
• ARDS management changes the strategy: lung-protective ventilation, proning when indicated and conservative fluids after shock stabilisation.