A middle aged man presents critically unwell with features to suggest septic shock and cardiogenic shock Initial bloods:

NAGMA with high lactate, hypoNa, hyperK

After 2 litres:

Worsening of acid base status consistent with N/Saline fluid administration – increased Chloride and worsening pH/NAGMA but improving lactate

After 3 litres:

Further deterioration of acid base status, improving lactate

Features suggesting septic shock – temp, low BP, high WCC, high INR, high trop

Features of cardiogenic shock – cold peripheries, low BP, elevated troponin

ECHO showed small pericardial effusion but no focal ischaemia

Central access was obtained – inotropes started, ABs given and patient was sent to ICU

Patient deteriorated in ICU requiring intubation and high dose inotropes. Viral PCR showed Influenza but no obvious source for infection and no growth on cultures about 3 days later.