Managment of Urosepsis in a Private Surgical Hospital - anzuns

Urosepsis
Julie Hedley
September 2012

Definition of Urosepsis
Sepsis caused by
infection of the
urinary tract
and / or male
genital organs
(prostate)

Etiology of Sepsis
Elderly patients
The severity of
sepsis depends
mostly upon the host
response
Diabetics
Immunosuppressed
- transplant recipients
- cancer pts / chemo/steroids
- AIDS

Pathophysiology
For urosepsis to be
established,
pathogens have to
reach the
bloodstream
Risk of bacteraemia
is increased in
- severe UTIs
- obstruction caused by
◦ Stones
◦ Stenosis
◦ Tumours (prostatic or urological)
◦ Pregnancy
◦ Anomalies of the Urinary Tract
◦ Following operations

Sepsis Urosepsis
Bloodstream
Skin
Gram negative bacteria
Escherichia coli
Pseudomonas aeruginosa
Respiratory tract
Gastrointestinal tract
Genitourinary tract
Klebsiella
Proteus
Gram positive bacteria
Enetercoccus

Epidemiology
Urosepsis accounts
for approx. 25% of
all sepsis cases
More common in
men than women
Severe Sepsis:
Pulmonary 50%
Abdominal infections 24%
UTI 5%
Severe sepsis –
UTI’s 5%

Sepsis
Systemic
inflammatory
response to infection
Diagnosis when 2 or
more of the following
criteria are present
Temp > 38 or < 36
HR > 90/min
Resps > 20/min or PaCo2 <
32mm Hg
WBC > 12,000 or < 4,000

Sepsis
Sepsis can only be
diagnosed when SIRS
occurs in the presence of
a suspected or confirmed
infection
Severe sepsis (i.e.
multiple organ
dysfunction)
Septic shock (i.e.
severe sepsis with
hypotension despite
adequate fluid
resuscitation) and
death

Clinical presentation
Sepsis
Fever or hypothermia
Hyperventilation
Chills
Shaking
Warm skin
Skin lesions
Lethagy
Confusion
Coma
Hyperglycaemia
Ileus
Muscle weakness
Increased cardiac output
Severe sepsis/septic
shock
Liver dysfunction (jaundice)
Cool skin
Pancreatitis
Renal failure
Decreased cardiac output
Acute respiratory distress
syndrome
Multiple-organ dysfunction
syndrome
Encephalopathy
Neuropathy
DIC

Diagnosis & Management
A rapid diagnosis is
critical to meet the
requirements of early
goal directed therapy
Nursing assessment
Observations/recordings
Medical intervention
O2 Therapy
Fluid resuscitation
Examination uro-genital
tract
Urinalysis
Blood test
Urine & blood cultures
Antibiotic Therapy

Case Study
Optical Urethrotomy
……Urosepsis
Mr C – age 83yrs
Medical History:
IHD
CABG
PE- post cholecystectomy
40yrs ago
Observations:
BMI 41 Weight 110kgs
T 37, HR 70, BP 163/85,
R/R 16, O2 sats 98%

Optical Urethrotomy
Telescopic inspection
of the urethra and
bladder with incision
of a stricture
Operation time 60 mins
Recovery uneventful
Perfalgan & Clexane in
PACU
Obs stable

RTW
After returning to the
ward at 1020hrs Mr C
was comfortable and
settled, was taking
oral fluids and had
managed a light diet.
His wife was present
Temp 36.9
HR 58 (regular)
RR 16
B/P 130/69
O2 Sats 95% on room air
Pain score 2/10
Analgesia declined
IDC light haematuria
At 1120 the status quo
remained

At 12midday…
A member of the
kitchen staff alerted
the RN that Mr C had
asked her for another
blanket….she said he
appeared to be
shivering
The RN immediately went to
check her patient…Mr C
Flushed in the face
Shivering severely
Experiencing a rigor
Temp 37.1
Pulse 84
B/P 195/116
Resps 20
O2 Sats on room air 92%

Immediate action…
The RN’s immediate
response was to start
a nursing assessment
to establish why Mr C
was experiencing
these symptoms
ABCDE
O2 via nasal prongs @ 3L
Circulatory status
Pain score remained 2/10
No increase in resp effort
respiratory infection
catheter blocked
full bladder
infection somewhere
2hrs post op – too early
to be surgery related!!

1220 hrs
Following a nursing
assessment, the RN
phoned the
anaesthetist
Suspected sepsis
Verbal order for stat dose
of ABs (Amoxicillin)
Urgent bloods
CBC & Urea & Electrolyes
Advise surgeon
Confirmed anaesthetist’s
suspicion – bacteraemia
Verbal order for stat dose
of Gentamycin
Urgent blood cultures,
TNT, CSU

Team work
Consulted with the
Team Leader &
decision made to
transfer Mr C to
HDW.
Ward nurses took
over the care of RNs
other patients
T/L arranged for the
urgent specimens to
be taken

Rapid deterioration…
After transfer to HDW
Mr C’s condition
began to rapidly
deteriorate and by
1330 he was showing
signs of confusion
and irritability
Temp 38.9 – 39.1
B/P 232/106
HR 92
Resps 29
O2 sats 99% @ 3L
ABs @ 1230
IV fluids @ 500mls/hr
Oral Paracetomol
Cooling cares
Support for Mrs C

Test results…
At 1340hrs the
surgeon phoned to
advise the
preliminary test
results –
Enterococcus
Bacteraemia…
sensitive to
Amoxycillin
Possible that the
organism was already in
Mr C’s urinary system
before having surgery

By 1500hrs…
Mr C remained
febrile, confused,
and irritable.
UO began to drop –
struggling to maintain
30ml/hr
His UO from RTW was
800mls – however…
O2 sats falling even with
O2 @ 4-6L/min (94-96%)
HR & RR elevated

Transfer to the DHB
Following a review by
the surgeon a
decision was made to
transfer Mr C to the
DHB for further
assessment &
management

Discharge summary
Full recovery
Discharged after
5 days
Optical Urethrotomy
and insertion of SPC
Discharge diagnosis –
Urosepsis post Optical
Urethrotomy
2° diagnosis –
- delirium
- atelectasis
- mild hypokalaemia
- sweat rash
Discharge meds included
10 days of oral antibiotics
IDC in situ on discharge
F/U appt with urologist

Reflection
This case study
reflects on the
management of a
unexpected complex
clinical situation and
the skill in which it
was handled
Communication
Assessment
Teamwork
Nursing knowledge
Efficiency
Cultural needs met

To conclude…
The shorter the
time to effective
treatment, the
higher the success
rate
Early recognition of
symptoms
Early diagnosis
Early oxygen treatment
Early fluid treatment
Early antibiotic therapy
Comprehensive teamwork

References
Baird, N. (2012) Clinical Care Reflection. An unpublished
refection
Cystoscopy and Optical Internal Urethrotomy Peri-op
Instructions. Retrieved from
http://www.usadelaware.com/medicalbriefs/cystoscop
yandopticalinternalurethr...
Wagenlehner F.M.E, Wolfgang W, Naber K.G. (2007)
Pharmocokinetic Caracteristics of Antimicrobials and
Optimal Treatment of Urosepsis. Clin Pharmacolkinet
2007; 46(4)
Wagenlehner F.M.E, Pilatz A, Naber K.G. Weidner W. (2008)
Therapeutic challenges of urosepsis. European Journal
of Clinical Investigation 2008; 38: 45-49