Here's an interesting case I had in the ER today.... 62 yo M w/ Hx CABG, DM, HTN, ESRD on HD, who was called by his PMD and told to come to the ER for 2/2 + blood cultures for Gram + cocci in clusters. On presentation he had a temp of 40.3, BP 91/50, HR 87, 02 94% RA. He complained of a mild HA and displayed nuchal and back rigidity. I did an LP and administered meningitic doses of antibiotics. His glucose was also noted to be in the 500 club w/ an anion gap of 20, resulting in an insulin gtt. EKG revealed A-flutter w/ 5:1 conduction and ST depressions of 3 mm in leads V3-V6 w/ corresponding TWI's (old EKG was paced). During my exam and LP his pressure was in the 110's; however, about 2 hrs later his BP steadily dropped into the 70's despite 2 liters NS bolus. His 02 sat was 98% on 6L NC, but he denied SOB, CP, and was mentating normally in no apparent distress. So here's my question.... How would you manage a septic hypotensive patient in A-flutter w/ 5:1 conduction of unknown duration (HR in the 60's)?