Sepsis (pediatrics) Quiz: Ace Your Exams

A 7-year-old boy is admitted to the pediatric intensive care unit with a diagnosis of septic shock secondary to occult bacteremia. The patient has a history of acute lymphoblastic leukemia and has been undergoing chemotherapy treatment for the past three months. The patient was brought to the emergency department yesterday with acute onset of fever and chills. He was provided with resuscitative measures, including intravenous antibiotic therapy and fluid boluses totaling 60 ml/kg. Blood cultures grow gram-negative rods. The patient's initial lactic acid level drawn yesterday was 2.7 mmol/L. Today, temperature is 38.8°C (101.8°F), blood pressure is 82/38 mmHg, pulse is 138/min, respiratory rate is 24/min, and oxygen saturation is 95% on room air. He is 24^th percentile for weight and 49^th percentile for height. The patient is pale and ill-appearing. Cardiopulmonary examination reveals delayed capillary refill, bounding pulses, and faint rales bilaterally. A port is in place over the left upper chest wall without surrounding fluctuance, erythema, or tenderness to palpation. Repeat laboratory studies are obtained and detailed below. Which of the following is the best next step in management?

Laboratory Value	Result	Reference Range
Serum Chemistry
Sodium	133 mEq/L	138-145 mEq/L
Potassium	3.9 mEq/L	4.1-5.8 mEq/L
Chloride	97 mEq/L	96-106 mEq/L
Creatinine	2.4 mg/dL	0.1-0.5 mg/dL
Albumin	3.0 g/dL	3.7-5.6 g/dL
Plasma
Lactic acid	5.1 mmol/L	0.6-2 mmol/L
Complete Blood Count
Hemoglobin	11.5 g/dL	11.5-15.5 g/dL
Hematocrit	33.8%	35-45%
Leukocyte count	21,100/mm3	4,300-11,000/mm3
Platelet count	55,000/mm3	150,000-400,000/mm3