Clinical Case #medtwitter A 16-year-old male, recently diagnosed with acute myeloid leukemia (AML), was admitted with febrile neutropenia on Day 8 post-chemotherapy. He was started on empirical IV antibiotics and remained vitally stable. Clinical Deterioration: On the next day, he develops hypotension (MAP: 52 mmHg), persistent fever, and decreased level of consciousness. The staff calls you for urgent assessment. --- Management of Septic Shock in Febrile Neutropenia 1. Immediate Resuscitation (First Hour - Golden Hour) Airway & Breathing Ensure patent airway, provide oxygen supplementation (target SpO₂ > 92%). If respiratory failure develops, consider intubation and mechanical ventilation. Circulation Rapid IV fluid resuscitation: 30 mL/kg crystalloid (ringer’s lactate or normal saline) bolus over the first hour. Frequent reassessment: If MAP remains <65 mmHg, initiate vasopressors. Vasopressor Support (if persistent hypotension) First-line: Norepinephrine (start at 0.1 mcg/kg/min, titrate to maintain MAP > 65 mmHg). If refractory shock: Add vasopressin (0.03 U/min) or epinephrine. 2. Identify and Control the Source of Infection Blood cultures (peripheral & central line) before antibiotics. Urine, sputum, and fungal cultures if indicated. Chest X-ray / CT scan (evaluate for pneumonia, invasive fungal infections). 3. Escalate Empirical Antibiotic Therapy If already on broad-spectrum antibiotics (e.g., piperacillin-tazobactam or meropenem), consider adding: Gram-positive coverage: Vancomycin (if central line infection suspected). Consider giving dual gram negative coverage initially to cover CRE. Antifungal therapy: Start liposomal amphotericin B or echinocandin (caspofungin) if febrile for >4–5 days despite antibiotics. 4. Adjunctive Therapies Steroids: Consider hydrocortisone 50 mg IV q6h if refractory shock despite fluids and vasopressors. G-CSF (Filgrastim): Consider if prolonged neutropenia expected (>10 days).( in active disease we avoid gcsf generally) 5. Monitor and Support Organ Function ICU admission for close hemodynamic monitoring. Serum lactate, blood gases, renal function monitoring. Urine output target > 0.5 mL/kg/hr (monitor for acute kidney