1.

A 30-year-old woman in her last trimester of pregnancy

suddenly develops massive swelling of the left lower extremity.
Which of the following would be the most appropriate workup
and treatment at this time?
a. Venography and heparin
b. Duplex ultrasonography and heparin
c. Duplex ultrasonography, heparin, and vena caval filter
d. Duplex ultrasonography, heparin, warfarin (Coumadin)
e. Impedance plethysmography, warfarin
The correct answer is B.
Duplex ultrasound is the diagnostic modality of choice for
detection of infrainguinal deep venous thrombosis (DVT).
Although venography is the gold standard, it is no longer
routinely used, given the risks of local (thrombosis, pain) and
contrast-related (allergic reaction, renal failure) complications.
Impedance plethysmography, which measures changes in
volume in the lower extremity as related to blood flow, is also
used infrequently due to the superiority of duplex scanning in
detecting DVTs. In pregnant women, anticoagulation for
treatment of DVT is achieved with heparin, which does not
cross the placenta, rather than warfarin, which is associated
with the risk of spontaneous abortion and birth defects. The
vena caval filter is not indicated because there is no
contraindication to heparin therapy and no evidence of failure
of anticoagulation therapy (pulmonary embolus in the face of
adequate anticoagulation).

2. A 65-year-old man has an enterocutaneous fistula originating

in the jejunum secondary to inflammatory bowel disease.
Which of the following would be the most appropriate fluid for
replacement of his enteric losses?
a. D5W
b. 3% normal saline
c. Ringer lactate solution
d. 0.9% sodium chloride
e. 6% sodium bicarbonate solution
The correct answer is C.
Bile and the fluids found in the duodenum, jejunum, and ileum
all have an electrolyte content similar to that of Ringer lactate.
Saliva, gastric juice, and right colon fluids have high K+ and low
Na + content. Pancreatic secretions are high in bicarbonate. It is
important to consider these variations in electrolyte patterns
when calculating replacement requirements following
gastrointestinal losses.
3. A 16-year-old adolescent boy with a history of severe
hemophilia A is undergoing an elective inguinal hernia repair.
Which of the following is the best option for preventing or
treating a bleeding complication in the setting of this disease?

a. Fresh-frozen plasma
b. Combination of desmopressin and fresh-frozen plasma
c. DDAVP
d. Combination of ε-aminocaproic acid and desmopressin
e. Factor IX concentrate
The correct answer is D (Townsend, pp 118-119)
Hemophilia A is a coagulation disorder resulting from a
deficiency or abnormality of factor VIII.
Desmopressin (DDAVP) is a synthetic analogue of antidiuretic
hormone that increases levels of factor VIII and von Willebrand
factor. DDAVP can be used alone for mild hemophilia A, but is
ineffective in severe forms of the disease. For severe
hemophilia A, DDAVP is given in combination with an inhibitor
of fibrinolysis such as ε-aminocaproic acid (AMICAR).
Although FFP contains factor VIII, the levels are too low to
prevent or control bleeding in hemophiliacs. Other agents used
in treatment of hemophilia A include cryoprecipitate and
specific factor VIII concentrates.

4. On postoperative day 5, an otherwise healthy 55-year-old

man recovering from a partial hepatectomy is noted to have a
fever of 38.6°C (101.5°F). Which of the following is the most
common nosocomial infection postoperatively?

a. Wound infection
b. Pneumonia
c. Urinary tract infection
d. Intra-abdominal abscess
e. Intravenous catheter-related infection
The correct answer is C (Brunicardi, pp 336-337).
The most common nosocomial infection is a urinary tract
infection. Treatment consists of removal of an indwelling
catheter as soon as possible and antibiotic therapy for cultures
with greater than 100,000 CFU/mL. Pneumonias, wound
infections, intra-abdominal abscesses, and catheter-related
bloodstream infections are also all causes of nosocomial
infections, and a workup of a postoperative fever should also
include careful examination of the patient and other diagnostic
tests as appropriate (chest x-ray, blood cultures,
abdominal/pelvic CT scan).

5. A 78-year-old man with a history of coronary artery disease

and an asymptomatic reducible inguinal hernia requests an
elective hernia repair. Which of the following would be a valid
reason for delaying the proposed surgery?

a. Coronary artery bypass surgery 3 months earlier

b. A history of cigarette smoking
c. Jugular venous distension
d. Hypertension
e. Hyperlipidemia
The correct answer is C (Townsend, pp 252-256).
The work of Goldman and others has served to identify risk
factors for perioperative myocardial infarction. The highest
likelihood is associated with recent myocardial infarction:
the more recent the event, the higher the risk up to 6 months.
It should be noted, however, that the risk never returns to
normal. A non-Q-wave infarction may not have destroyed much
myocardium, but it leaves the surrounding area with borderline
perfusion, thus the particularly high risk of subsequent
perioperative infarction. Evidence of congestive heart failure,
such as jugular venous distention, or S3 gallop also carries a
high risk, as does the frequent occurrence of ectopic beats. Old
age (>70 years) and emergency surgery are risk factors
independent of these others. Coronary revascularization by
coronary artery bypass graft (CABG) tends to protect against
myocardial infarction. Smoking, diabetes, hypertension, and
hyperlipidemia (all of which predispose to coronary artery
disease) are surprisingly not independent risk factors, although
they may increase the death rate should an infarct occur.
The value of this information and data derived from further
testing is that it identifies the patient who needs to be
monitored invasively with a systemic arterial catheter and
pulmonary arterial catheter. Most perioperative infarcts occur
postoperatively when the third-space fluids return to the
circulation, which increases the preload and the myocardial
oxygen consumption. This generally occurs around the third
postoperative day.

6. A 74-year-old woman with a history of a previous total

abdominal hysterectomy presents with abdominal pain and
distention for 3 days. She is noted on plain films to have dilated
small-bowel and air-fluid levels. She is taken to the operating
room for a small-bowel obstruction. Which of the following
inhalational anesthetics should be avoided because of
accumulation in air-filled cavities during general anesthesia?

a. Diethyl ether
b. Nitrous oxide
c. Halothane
d. Methoxyflurane
e. Trichloroethylene
The correct answer is B (Townsend, p 432).
Nitrous oxide has a low solubility compared with other
inhalation anesthetics; nitrous oxide is more soluble in blood
than nitrogen and is the only anesthetic gas less dense than air.
As a result of these properties, nitrous oxide may cause
progressive distension of air-filled spaces during prolonged
anesthesia. Since nitrous oxide diffuses into gas-filled
compartments faster than nitrogen can diffuse out, its use can
lead to worsened distention, which may be undesirable (eg, in
an operation for intestinal obstruction).

7. A 64-year-old man with history of severe emphysema is

admitted for hematemesis. The bleeding ceases soon after
admission, but the patient becomes confused and agitated.
Arterial blood gases are as follows: pH 7.23; PO2 42 mm Hg;
PCO2 75 mm Hg. Which of the following is the best initial
therapy for this patient?

a. Correct hypoxemia with high-flow nasal O2

b. Correct acidosis with sodium bicarbonate
c. Administer 10 mg intravenous dexamethasone
d. Administer 2 mg intravenous Ativan
e. Intubate the patient

The correct answer is E (Brunicardi, pp 59-60).

The patient is suffering from respiratory acidosis, caused by the
accumulation of CO2, and hypoxemia. Both disturbances can be
resolved with endotracheal intubation and ventilatory support.
Agitation can be an early sign of hypoxemia in an elderly
patient and should never be ignored. Benzodiazepines such as
Ativan in this patient will cause stupor and worsen his
hypoxemia and respiratory acidosis. Bicarbonate should not be
administered because buffer reserves are already adequate
(serum bicarbonate is still 34 mEq/L based on the Henderson-
Hasselbalch equation).

8. A 22-year-old man sustains severe blunt trauma to the back.

He notes that he cannot move his lower extremities. He is
hypotensive and bradycardic. Which of the following is the best
initial management of the patient?

a. Administration of phenylephrine
b. Administration of dopamine
c. Administration of epinephrine
d. Intravenous fluid bolus
e. Placement of a transcutaneous pacer

The correct answer is D (Brunicardi, pp 107-108).

The patient is in neurogenic shock as a result of a spinal cord
injury. Neurogenic shock is characterized by loss of sympathetic
tone peripherally as well as bradycardia owing to loss of the
reflexive increase in heart rate in response to hypotension.
Initial treatment is with fluid resuscitation followed by initiation
of vasoconstrictors such as dopamine or phenylephrine.
Hypovolemia caused by hemorrhage should also be ruled out in
trauma patients.

9. A 30-year-old man is scheduled for a laparoscopic

cholecystectomy for biliary colic. He reports a family history of
prolonged paralysis during general anesthesia. Which of the
following medications should be avoided during his procedure?

a. Succinylcholine
b. Vecuronium
c. Pancuronium
d. Halothane
e. Etomidate

The correct answer is A (Brunicardi, pp 1734-1739).

The family history is suggestive of a pseudocholinesterase
deficiency which prolongs the effects of succinylcholine, a
depolarizing neuromuscular blocking agent, as well as of
mivacurium, a non-depolarizing agent. Vecuronium,
pancuronium, and cis-atracurium are other non-depolarizing
agents that are not affected by this enzyme deficiency.
Etomidate is used for rapid sequence induction and is not
affected by pseudocholinesterase deficiency; etomidate does
block steroid synthesis and has been associated with acute
adrenal insufficiency, but the clinical relevance of the resultant
insufficiency is controversial.

10. A 55-year-old woman has been hospitalized because of

recurrent pancreatitis, ARDS, prolonged ileus, and need for
parenteral nutrition. She demonstrates weakness, lassitude,
orthostatic hypotension, nausea, and fever. Which of the
following abnormalities is most likely to explain these
symptoms?
a. Hypothermia
b. Hypokalemia
c. Hyperglycemia
d. Hyponatremia
e. Hypervolemia

The correct answer is D(Brunicardi, pp 1402-1403).

Clinical manifestations of adrenocortical insufficiency include
hyperkalemia, hyponatremia, hypoglycemia, fever, weight loss,
and dehydration. There is excessive sodium loss in the urine,
contraction of the plasma volume, and perhaps hypotension or
shock. Classic hyperpigmentation is present in chronic Addison
disease only. Addison disease may present in newborns as a
congenital atrophy, as an insidious chronic state often caused
by tuberculosis, as an acute dysfunction secondary to trauma or
adrenal hemorrhage, or as a semiacute adrenal insufficiency
seen during stress or surgery. In this last instance, signs and
symptoms include nausea, lassitude, vomiting, fever,
progressive salt wasting, hyperkalemia, and hypoglycemia. It
may be confirmed by measurements of urinary Na+ loss and
absence of response to adrenocorticotropic hormone (ACTH).
11. A 42-year-old man who was in a house fire is transferred to
your burn unit. He has singed nose hairs and facial burns. Direct
laryngoscopy in the emergency room demonstrates pharyngeal
edema and mucosal sloughing. He has 60% total body surface
area burns. Which of the following is the next step in the
management of this patient?

a. Hyperbaric oxygen
b. Intravenous steroids
c. Inhaled steroids
d. Bronchoscopy
e. Intubation

The correct answer is E(Brunicardi, pp 201-202; Mulholland, pp

220-221).
The patient requires intubation because of suspicion of upper
airway burns. Clinical suspicion should be increased given the
singed nose hairs and facial burns. Intubation should be
considered in the presence of posterior pharyngeal edema,
mucosal sloughing, or carbonaceous sputum on direct
laryngoscopy. Significant upper airway edema can result of
upper airway burns, particularly 12 to 24 hours post-injury.
Bronchoscopy can be used to evaluate for lower airway burn
injuries, but would not change management in this patient
given the high clinical suspicion for airway burn injuries and the
need for intubation. Inhaled or intravenous steroids for airway
burn injuries are not indicated in patients with large burns due
to the increased risk of infections. Carbon monoxide poisoning
is treated with 100% inhaled oxygen; hyperbaric oxygen is used
in patients with neurologic symptoms and small burns as it
reduces the half-life of carboxyhemoglobin. However, the risks
outweigh the benefits in patients with large burns.
12. A 45-year-old woman is seen with wasting of the intrinsic
muscles of the hand, weakness, and pain in the wrist. Which of
the following nerves has most likely been injured?

a. Ulnar nerve
b. Radial nerve
c. Brachial nerve
d. Axillary nerve
e. Median nerve

The answer is a (Townsend, pp 2154-2158).

The ulnar nerve innervates 15 of the 20 intrinsic muscles of the
hand. The musculocutaneous, radial, ulnar, and median nerves
are all important to hand function. The musculocutaneous and
radial nerves allow forearm supination; the radial nerve alone
innervates the extensor muscles. The median nerve is the “eye
of the hand” because of its extensive contribution to sensory
perception; it also maintains most of the long flexors, the
pronators of the forearm, and the thenar muscles.

13. A 35-year-old woman undergoes an elective laparoscopic

cholecystectomy for symptomatic cholelithiasis. Which of the
following wound classes best describes her procedure?

a. Class I, Clean
b. Class II, Clean/contaminated
c. Class III, Contaminated
d. Class IV, Dirty
e. None of the above

The correct answer is B(Brunicardi, pp 123-124).

Clean wounds are those in which no part of the respiratory,
gastrointestinal, or genitourinary tract is entered. Examples
include herniorrhaphy and breast surgery. Clean-contaminated
wounds encompass those cases in which these systems are
entered, but without evidence of active infection or gross
spillage. Examples include elective cholecystectomy or elective
colon resection with adequate bowel preparation.
Contaminated wounds include open accidental wounds
encountered early after injury, those with extensive
introduction of bacteria into a normally sterile area of the body,
or gross spillage of viscus contents such as from the intestine.
Examples include penetrating abdominal trauma, large tissue
injury, and enterotomy during bowel obstruction.
Dirty wounds include traumatic wounds in which a significant
delay in treatment has occurred and in which necrotic tissue is
present, those created in the presence of purulent material,
and those involving a perforated viscus accompanied by a high
degree of contamination. Examples include perforated
diverticulitis and necrotizing soft tissue infections.

14. A 24-year-old firefighter sustains 30% total body surface

area (TBSA) burns to his torso, face, and extremities. His
wounds are treated topically with silver nitrate. Which of the
following complications is associated with use of this agent?

a. Hypernatremia
b. Metabolic acidosis
c. Hyperchloremia
d. Neutropenia
e. Hyponatremia

The correct answer is E(Brunicardi, p 202).

The 3 main topical agents used to treat burns include silver
nitrate, silver sulfadiazine, and mafenide acetate.
Complications of silver nitrate are electrolyte abnormalities
(hyponatremia, hypokalemia, hypocalcemia, hypochloremia)
and methemoglobinemia. The main complication with silver
sulfadiazine is neutropenia; mafenide acetate causes metabolic
acidosis secondary to inhibition of carbonic anhydrase.

15. A 65-year-old man sustains a 50% TBSA burn while burning

trash in the backyard. The patient is resuscitated with lactated
Ringer (LR) solution using the Parkland formula and a weight of
80 kg. What is the rate of LR given in the first 8 hours?

a. 100 mL/h
b. 500 mL/h
c. 1000 mL/h
d. 5000 mL/h
e. 10,000 mL/h
The correct answer is C (Brunicardi, p 200).
The Parkland formula recommends 4 mL LR/kg for each percent
TBSA burned over the first 24 hours, with one-half of the
amount administered in the first 8 hours, and the remaining
half over the next 16 hours.
4 mL/kg × 80 (kg) × 50% TBSA = 16,000

16,000/2 = 8000
8000 (mL)/8 (hours) = 1000 mL/h

16. A teenage boy falls from his bicycle and is run over by a
truck. On arrival in the emergency room (ER), he is awake and
alert and appears frightened but in no distress. The chest
radiograph suggests an air-fluid level in the left lower lung field
and the nasogastric tube seems to coil upward into the left
chest. Which of the following is the next best step in his
management?

a. Placement of a left chest tube

b. Thoracotomy
c. Laparotomy
d. Esophagogastroscopy
e. Diagnostic peritoneal lavage
The correct answer is C(Townsend, pp 500-501).
The patient has an acute diaphragmatic rupture, which occurs
in about 4% of patients who sustain either blunt abdominal or
chest trauma, and should be treated with immediate
laparotomy, which allows both for examination of the intra-
abdominal solid and hollow viscera for associated injuries and
for adequate exposure of the diaphragm to allow secure repair.
Because of the risk of vascular compromise of the contents of
the hernia, exacerbated by the negative thoracic pressure,
acute diaphragmatic rupture should be repaired immediately.
Diagnosis may be difficult. The finding of an air-fluid level in the
left lower chest, with a nasogastric tube entering it after blunt
trauma to the abdomen, is diagnostic of diaphragmatic rupture
with gastric herniation into the chest. Esophagogastroscopy is
of limited value. CT scanning and MRI may be useful adjuncts,
but neither can definitively rule out diaphragmatic rupture.
Diagnostic peritoneal lavage is neither sensitive nor specific for
diaphragmatic injuries, particularly in the absence of significant
hemorrhage. Diaphragmatic repair can be accomplished via the
left chest, but laparotomy is the procedure of choice for acute
traumatic rupture for the stated reasons.
17. A 22-year-old woman who is 4 months pregnant presents
after a motor vehicle collision complaining of abdominal pain
and right leg pain. She has an obvious deformity of her right
femur. She is hemodynamically stable. Which of the following is
the best next step in her management?

a. Observation with serial abdominal exams

b. Diagnostic peritoneal lavage
c. Plain film of the abdomen with a lead apron as a shield
d. Focused assessment with sonography for trauma (FAST)
examination of the abdomen
e. MRI of the abdomen

The correct answer is D (Moore, pp 831-836).

The goals in performing a diagnostic workup and managing a
pregnant trauma patient are the same as those for any trauma
patient. While radiologic imaging tests should be minimized,
indicated tests should not be delayed or deferred because of
concern of fetal exposure to radiation. FAST is the initial
diagnostic modality of choice in a pregnant patient with
abdominal trauma. While diagnostic peritoneal lavage can be
used to evaluate the abdomen, it is invasive and has been
largely replaced in centers by FAST. Plain films of the abdomen
are not typically used in the workup of abdominal trauma
patients. CT scanning can be performed in hemodynamically
stable pregnant patients. MRI is not associated with ionizing
radiation but is not typically rapidly
available for use in evaluation of abdominal trauma.

18. A 32-year-old man is in a high-speed motorcycle collision

and presents with an obvious pelvic fracture. On examination,
he has a scrotal hematoma and blood at his urethral meatus.
Which of the following is the most appropriate next step in his
management?

a. Placement of a Foley catheter

b. Cystoscopy
c. CT of the pelvis
d. Retrograde urethrogram
e. Nephrostomy tube placement

The correct answer is D(Moore, pp 805-806).

If a urethral injury is suspected, a retrograde urethrogram
should be performed before attempting to place a Foley
catheter. If there is a urethral disruption, a suprapubic catheter
should be placed. Urethral injuries can be associated with pelvic
fractures, and suspicion of a urethral injury should be increased
if any of the following signs are present: blood at the urethral
meatus, a scrotal hematoma, or a free-floating prostate on
rectal examination.

19. A hypertensive 47-year-old man is proposed for kidney

transplantation. He is anemic but is otherwise functional.
Which of the following would preclude renal transplantation?

a. Positive cross-match
b. Donor blood type O
c. Two-antigen HLA match with donor
d. Blood pressure of 180/100 mm Hg
e. Hemoglobin level of 8.2 g/dL

The correct answer is A(Townsend, pp 693-694).

A positive cross-match means that the recipient has circulating
antibodies that are cytotoxic to donor-strain lymphocytes. This
incompatibility, which almost always leads to an acute humoral
rejection of the graft, precludes transplantation. Blood type
matching prior to organ allograft is similar to cross-matching
prior to transfusion; O is the universal donor and AB the
universal recipient. Minor blood group factors do not appear to
act as histocompatibility antigens.
Matching of HLA antigens in cadaveric renal transplants may
improve graft survival, but the impact is relatively minor. While
attempts are made to pair recipient and donor by tissue typing,
a 2-antigen match is perfectly acceptable and even 0-antigen
matches can be transplanted with good results.
Neither hypertension nor anemia is a contraindication to
transplantation; indeed, hypertension may be cured or
ameliorated following successful transplantation. Patients with
end-stage renal failure generally are anemic and can be
transfused, if necessary, intraoperatively or postoperatively.
Anemia generally also improves following transplantation
because of increased erythropoietin production by the graft.

20. A patient with a solid malignancy discusses chemotherapy

with his oncologist. He is interested in the risks of the
treatment. What is the primary toxicity of doxorubicin
(Adriamycin)?

a. Cardiomyopathy
b. Pulmonary fibrosis
c. Peripheral neuropathy
d. Uric acid nephropathy
e. Hepatic dysfunction
The correct answer is A(Brunicardi, pp 260-262, 1294).
Doxorubicin, an antibiotic derived from Streptomyces species,
has activity against sarcomas and carcinomas of the breast,
liver, bladder, prostate, head and neck, esophagus, and lung. Its
major side effect is production of a dilated cardiomyopathy.
Patients receiving this agent should have an echocardiogram
before and after treatment in order to monitor potential
cardiac toxicity.

STRUCTUIRAL / FILL IN THE GAP

1. A 65-year-old man with a 35% body surface area (BSA)
burn develops hyperkalemia after induction. Which agent
is responsible for this?
Answer: Succinylcholine

2. A 43-year-old man with a painless ulceration over the

left medial malleolus with surrounding brawny
induration. What is the likely diagnosis?
Answer: Venous ulcer
3. What stage is this breast cancer? Tumor not palpable,
clinically positive ipsilateral axillary lymph nodes fixed to
one another, no evidence of metastases.
Answer: Stage III

4. What is the next line of management for this patient?

A 49-year-old woman undergoes biopsy of a 5.0-cm left
breast mass; she has no palpable axillary lymph nodes.
Biopsy of the mass shows cystosarcoma phyllodes.
Answer: Wide local excision
Cystosarcoma phyllodes is treated with wide local
excision with at least 1-cm margins; axillary
lymphadenectomy is not routinely recommended in the
absence of clinically suspicious nodes. There are few
indications for radical mastectomy, as it is both more
traumatic and more disfiguring than any other method of
local control of breast cancer and offers no greater
survival benefit.
5. What is the diagnosis is this vignette?
A 62-year-old man presents with right upper quadrant
abdominal pain and jaundice. He is afebrile with normal
vital signs. On laboratory findings he has elevated levels
of bilirubin and alkaline phosphatase. Ultrasound
demonstrates gallstones, normal gallbladder wall
thickness, no pericholecystic fluid, and a common bile
duct of 1.0 cm.
Answer: Choledocholithiasis
A gallstone remaining in the common bile duct is called
choledocholithiasis. Dilation of the common bile duct
occurs and a CBD size > 4 mm is suspicious for a CBD
stone. These patients may be asymptomatic, have
abdominal pain, or progress to develop cholangitis
depending on the status of the gallstone in the common
bile duct.

6. What is the diagnosis here?

A 36-year-old woman presents with right upper quadrant
abdominal pain and jaundice. She is febrile and
tachycardic. On laboratory results she has leukocytosis
and elevated levels of bilirubin and alkaline phosphatase.
Ultrasound demonstrates gallstones, normal gallbladder
wall thickness, no pericholecystic fluid, and a common
bile duct of 1.0 cm.
Answer: Cholangitis
Stones that become stuck in the common bile duct cause
stasis of bile in the biliary system which can lead to
cholangitis. The symptoms of cholangitis are right upper
quadrant abdominal pain, fever, and jaundice (Charcot
triad). Cholangitis is a life-threatening condition requiring
emergent ERCP with stone extraction and common bile
duct decompression.

7. What is the definitive surgical intervention in this 37-

year-old man with a 10-year history of ulcerative colitis
who has a sessile polyp 10 cm from the anal verge with
high-grade dysplasia?
Answer: Total proctocolectomy with ileoanal J-pouch
The definitive operation of choice for patients with UC is
total proctocolectomy with either end ileostomy or
ileoanal J-pouch anastomosis.
8. What Operative procedure is indicated in this 68-year-
old woman with fecal incontinence who presents with a
large fixed adenocarcinoma 3 cm from the anal verge?
Answer: Abdominoperineal resection
APR is also the procedure of choice for distal rectal
cancers that involve the sphincters or are too close to
obtain an adequate margin (2 cm) and in patients for
whom sphincter-sparing surgery is contraindicated
because of fecal incontinence

9. What is the likely diagnosis in this 23-year-old patient

with hypertension and increased urinary catecholamine
levels.
Answer: Pheochromocytoma
Mediastinal pheochromocytomas comprise less than 2%
of all pheochromocytomas. Their presentation is
consistent with overproduction of catecholamines,
resulting in paroxysmal or sustained hypertension.
Diagnosis is by measurement of urinary catecholamines
and their metabolites.
10. Which pharmacologic agent will you administer to
this 30-year-old man who presented with perforated
appendicitis and heart rate of 120 beats per minute,
blood pressure of 80/40 mm Hg, and central venous
pressure of 17 mm Hg.
The patient remains hypotensive after a continuous
infusion of dopamine.
Answer: Norepinephrine
Norepinephrine and dopamine are the first-line agents
used for septic shock. Norepinephrine acts on α-
adrenergic and β-adrenergic receptors, resulting in an
increase in afterload and glomerular perfusion pressure
with preservation of cardiac output. Norepinephrine is
associated with increase in urine output in hypotensive,
septic patients.