Q. A fit and healthy 65-year-old man has TRUS-guided prostate biopsy (TRUS-Bx) for a raised prostate-specific antigen (PSA). He had been given prophylactic 120 mg gentamicin (IV) and 500 mg metronidazole (PR), and subsequently started a 5-day course of 500 mg bd ciprofloxacin (PO). Then 36 hours later, the urology clinical nurse specialist is contacted by the patient’s wife, as he has developed severe flu-like symptoms. What advice do you give the urology clinical nurse specialist?
A. I would consider this a urological emergency and advise the urology clinical nurse specialist that I will contact the patient immediately, myself, without delay, advising him to attend accident and emergency urgently, where I would arrange to see him personally. I would strongly suspect that this patient has developed sepsis following TRUS-Bx.
Q. What is systemic inflammatory response syndrome - SIRS?
A. Response of the body to a variety of infectious (sepsis) or non-infectious (burns, pancreatitis) stimuli. Two of the criteria listed in Table 7.2 are required.
Table 7.2 Criteria for diagnosis of systemic inflammatory response syndrome
|
Temperature |
>38°C or <36°C |
|
HR |
>90/min |
|
RR |
>20/min or paCO2 <32 mm Hg (<4.3 kPa) or need for mechanical ventilation |
|
WCC |
<4 or >12 |
Q. How do you define sepsis, severe sepsis, septic shock and refractory septic shock?
A. The definitions are stated in Table 7.3.
Table 7.3 Definitions of sepsis, severe sepsis, septic shock and refractory septic shock
|
Term |
Definition |
|
Sepsis |
Proven infection causing SIRS. |
|
Severe sepsis |
Sepsis associated with organ dysfunction, hypoperfusion or hypotension. Hypoperfusion and perfusion abnormalities may include but are not limited to lactic acidosis, oliguria or an acute alteration of mental status. |
|
Septic shock |
Sepsis with hypotension despite fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to lactic acidosis, oliguria, or an acute alteration in mental status. |
|
Refractory septic shock |
Septic shock lasting > 1 hour; resistant to fluid resuscitation or pharmacological intervention. |
Q. How would you initially manage this patient?
A. I would consider this a urological emergency and see the patient myself, without delay. Based on international guidelines for surviving sepsis, on arrival, I would resuscitate the patient according to the sepsis 6 care bundle protocol used in my hospital (Table 7.4).
Table 7.4 Components of the sepsis 6 care bundle protocol
|
Component |
Notes |
|
100% oxygen |
I would give 15 Dmin via facemask with reservoir bag unless oxygen restriction necessary (e.g. in chronic CO2 retention aim for an SaO2 of 88%—92%). |
|
IV fluid bolus |
I would give a 500-1000 mL bolus of Hartmann’s through a large bore Venflon. Larger bolus may be required, e.g. if systolic BP less than 90 or lactate greater than 4, consider 1500-2000 mL. |
|
Blood cultures |
I would take blood cultures as per hospital guidelines. |
|
IV antibiotics |
I would administer as per hospital guidelines, in my practice to include gentamicin (3-5 mg/kg), metronidazole and a third-generation cephalosporin. |
|
Lactate + bloods |
I would take lactate on arterial or venous sample. I would also request FBC, U&E, LFT clotting (INR and APTT) and glucose if not yet done. I would also consider blood transfusion if Hb less than 7 (or above this with co-morbidities). |
|
Monitor urine output |
Consider catheter Monitor output hourly. Dip urine and send midstream specimen of urine (MSU)/catheter specimen urine (CSU). |
In addition to sepsis 6 care bundle protocol, I would contact my HDU/ITU anaesthetic colleagues and involve them early in the multidisciplinary management of this patient, as I am conscious of the high morbidity and mortality risk from this condition. If he is very unwell, he may need invasive monitoring or pharmacological support in the HDU/ITU setting.
Q. What are the most common organisms?
A. The most likely organisms would include gram-negative and anaerobic organisms, such as Escherichia coli, Klebsiella, Pseudomonas, Enterococci and Bacteroides.