The most appropriate next step in treatment is to administer another 1000-mL normal saline fluid bolus. This patient's findings are highly compatible with septic shock from a catheter-related bloodstream infection based on her fever, hypotension, organ failure (encephalopathy), and bacteremia. Aggressive fluid resuscitation and early administration of antibiotics are the highest priorities in managing septic shock. After receiving 1000 mL of fluid, this patient has no evidence of volume overload despite her known kidney injury, and a second bolus of fluid is indicated. Patients with sepsis typically need multiple fluid boluses to achieve adequate intravascular volume repletion.

Dobutamine is not appropriate because this patient's clinical picture is indicative of septic, rather than cardiogenic, shock. There are no changes on electrocardiogram, she has warm extremities consistent with a low systemic vascular resistance state, and she has signs of infection. Dobutamine is included in early goal-directed therapy protocols, but it is appropriate only after confirming adequate intravascular volume repletion. Also, the recent ProCESS trial calls into question dobutamine use in the absence of confirmed cardiac dysfunction.

The ProCESS trial included 31 emergency departments in the United States that were randomly assigned patients with septic shock to one of three groups for 6 hours of resuscitation: protocol-based early goal-directed therapy (EGDT); protocol-based standard therapy that did not require the placement of a central venous catheter, administration of inotropes, or blood transfusions; or usual care. Protocol-based resuscitation of patients in septic shock did not improve outcomes. In April 2014, the National Quality Forum downgraded use of central venous lines in the resuscitation of patients with septic shock to be at the discretion of clinicians. Because this patient has adequate peripheral venous access, the placement of a central venous catheter is not a priority management step.

Blood transfusion is not appropriate because this patient's stable hemoglobin level and manifestations of sepsis reliably exclude hypovolemic shock from acute blood loss. Crystalloids are the preferred choice for initial resuscitation of patients with sepsis because of their ready access, ease of rapid infusion, safety profile, and low cost. The efficacy of protocol-based blood transfusion as part of early goal-directed therapy is unclear given the results of the ProCESS trial.