Catecholamines
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Fatal sepsis complicated by septic shock: case report An 87-year-old man died due to a new episode of sepsis complicated by septic shock due to the immunosuppressive effects of catecholamines comprising dobutamine, dopamine, epinephrine and norepinephrine [routes not stated]. The man was admitted to the medical ICU in January 2013 due to clinical symptoms of an underlying severe sepsis, probably urinary in origin. Over the past few months, had been under a urologist monitoring because of enlarged prostate and recurrent urinary tract infections. He had been receiving cephalexin, dutasteride and tamsulosin. On admission, he was found to have Glasgow Coma Scale (GCS) score of 10 and chronic renal insufficiency. Samples for blood and urine cultures were taken and soon after his arrival to the medical ICU, an empirical antibiotic therapy with ciprofloxacin was given. About 24 hours after admission, he developed moderate hypotension (sign of septic shock) and started receiving norepinephrine [noradrenaline] at a maximum dose of about 0.08 µg/kg/min. Three hours later, dobutamine was added at an average dose of about 4.6 µg/kg/min. He developed metabolic acidosis and was placed on haemodialysis approximately 28h after admission. Three hours later, a sudden clinical deterioration was observed and respiratory insufficiency was noted. He required intubation with an initiation of mechanical ventilation. Therefore, haemodialysis was stopped. In addition to increasing the dose of norepinephrine and dobutamine, epinephrine [adrenaline] was started, followed by dopamine, with successive increasing dose of vasoactive drugs minute after minute. Eight hours after introduction of the four vasoactive drugs (i.e. dobutamine, dopamine, epinephrine and norepinephrine), his condition stabilised (i.e. his underlying septic shock improved). Ten hours after stabilisation, haemodialysis was resumed. During the first 12 hours of his hospital stay, he received a total of 130mg of norepinephrine (average dose of 2.124 µg/kg/min, 180.55 µg/min), 2500mg of dobutamine (mean 40.84 µg/kg/min, 3472.2 µg/min), 20mg of epinephrine (mean 0.33 µg/kg/min, 27.78 µg/min) and 1600mg of dopamine (average 26.14 µg/kg/min, 2222.22 µg/min). In the following 2–3 days, the dose of vasoactive drugs gradually decreased and then stopped, except for norepinephrine (0.01 to 0.02 µg/kg/min), which was also stopped the 6th day of hospitalisation. Two days later, mechanical ventilation was no longer needed and he was then extubated. His condition normalised (i.e. his underlying septic shock resolved). However, in the afternoon of hospital day 12, his BP was found to be decreased and CRP levels was found to be increased, conferring a new (second) episode of sepsis complicated by septic shock. Consequently, treatment with norepinephrine was re-started at low doses of about 0.037 µg/kg/min. However, he died on day 14 of his hospital stay because of new episode of sepsis complicated by septic shock. The authors concluded that the patient’s first episode of septic shock wa
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