Sepsis Fluid Resuscitation β A High-Yield UKMLA/PLAB Scenario (February 2025 Exam Question)π
Essential Insights for Medical Licensing Exams: Managing Sepsis and Septic Shock
Sepsis is a medical emergency that requires immediate recognition and resuscitation. This article breaks down a high-yield sepsis scenario from the February 2025 PLAB 1 exam, covering the latest NICE guidelines on fluid resuscitation. Understanding sepsis management is crucial for UKMLA, PLAB, and other international medical licensing exams.
π PLAB 1 Exam Case Scenario
A 72-year-old man is brought to the Emergency Department with fever, confusion, and dizziness. His family reports that he has been feeling unwell for the past two days with reduced oral intake and lethargy. He has a history of type 2 diabetes mellitus and chronic kidney disease stage 3.
On examination:
Temperature: 38.8Β°C
Blood pressure: 85/50 mmHg
Heart rate: 112 bpm
Respiratory rate: 26 breaths/min
Oxygen saturation: 95% on room air
Capillary refill time: 5 seconds
Jugular venous pressure: not elevated
No signs of pulmonary oedema
Investigations:
Lactate: 4.2 mmol/L (normal range: <2 mmol/L)
White cell count: 16 Γ 10βΉ/L (normal range: 4-11 Γ 10βΉ/L)
CRP: 170 mg/L (<10 mg/L)
Creatinine: 180 Β΅mol/L (previously 110 Β΅mol/L) (normal range: 70-150Β΅mol/L)
Urine dipstick: positive for nitrites and leukocytes
What is the most appropriate initial fluid resuscitation volume for this patient?
A) 250 ml of 0.9% sodium chloride
B) 500 ml of 0.9% sodium chloride over 15 minutes
C) 1000 ml of 0.9% sodium chloride
D) 30 ml/kg of 0.9% sodium chloride
E) 80 ml/kg of 0.9% sodium chloride
Answer with an explanation is provided below.
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β
Correct Answer: B) 500 ml of 0.9% sodium chloride over 15 minutes
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Clinical Reasoning and Explanation
Clinical Reasoning and Explanation
π Recognising Sepsis and Septic Shock
This patient meets the sepsis criteria, with fever, tachycardia, hypotension, and elevated inflammatory markers. The raised lactate (4.2 mmol/L) and acute kidney injury suggest septic shock, a life-threatening condition requiring urgent IV fluid resuscitation.
π¨ Initial Fluid Resuscitation in Sepsis (NICE NG51)
According to NICE Sepsis Guidelines (NG51), the first-line resuscitation for sepsis-induced hypotension or lactate β₯4 mmol/L is: β
500 ml of IV crystalloid (0.9% sodium chloride or Hartmannβs solution) over 15 minutes, followed by reassessment.
The goal is to restore perfusion, reduce lactate levels, and prevent multi-organ failure.
β Why the Other Options Are Incorrect
A) 250 ml of 0.9% sodium chloride
Too small a volume for sepsis resuscitation. Early aggressive fluid replacement is needed.
C) 1000 ml of 0.9% sodium chloride
A larger volume may be required, but fluids should be given in 500 ml boluses with reassessment to avoid fluid overload.
D) 30 ml/kg of 0.9% sodium chloride
This is the recommended total resuscitation volume, but it should be given in 500 ml increments with continuous reassessment.
E) 80 ml/kg of 0.9% sodium chloride
Excessive and dangerousβcan cause pulmonary oedema, especially in patients with chronic kidney disease (CKD).
Key Learning Points for PLAB 1 / UKMLA:
Sepsis Management: Immediate IV fluid resuscitation is critical in septic shock.
Correct Initial Fluid Volume: 500 ml of IV crystalloid over 15 minutes, then reassess.
Monitoring Response: After the first bolus, assess BP, urine output, lactate clearance, and signs of fluid overload.
Reassessment Strategy: If no improvement, give further 500 ml boluses up to 30 ml/kg, with continued monitoring.
Special Populations: Patients with renal impairment, heart failure, or fluid overload risk require careful monitoring.
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