Urosepsis in Diabetic Patient

Case: 70 year old M complaining of bilateral back pain and nausea.

PMHx:

• DM II
• HTN
• 2008 colon cancer surgery
• Weakness
• Chills
• Urinary symptoms

Vitals:

• BP 88/68 (Hypotensive)
• HR 112 (Tachycardic)
• RR 22 (Tachypneic)
• Blood glucose elevated
• 94% O2 sat a little low
• Temp 38.6 C (a little febrile)

Social Hx:

• Not eating a lot
• Not traveling
• Denies drugs/etoh
• Low BP, HR high together give you a sense of cardiac output (Preload issue). 

Labs:

• BUN/Cr ratio = 30 elevated 
• Bacteria in urine (3+ bacteria)
• Positive nitrites

DDx: 

• Think of systems like GI (apendectomy, apendicitis, colitis, diverticulitis), Respiratory (pneumonia), CNS (meningitis)
• Infection, inflammation, cancer, ischemia, vasculitis
• Diabetes patients more susceptible to infections because immune system is down, sugary environment for bacteria, and poor circulation. He could have an infection, metabolic acidosis, was given fluids and antibiotics (cetrax) and admitted to the hospital.
• RR rate high—> compensating for anion gap metabolic acidosis that was found on ABG. 
• Diagnosed with pyelonephritis.

What causes shock (end organ issue): 

• Septic infection (distributive, anaphylaxis)
• Hypovolemic (dehydration)
• Cardiogenic (obstructive, pump not working, pneumothorax, MI, blood loss)

Anion gap acidosis: 

• Lactate caused by poor perfusion (end organ issue), 
• Ketone acidosis (DKA, pH, urine ketones, blood ketones), 
• Nmeumonic: MUDPILES (methanol, uremia, diabetic ketoacidosis, propylene glycol, iron poisoning or isoniazid, lactic acidosis, ethylene glycol, salicylates)

Treatment: 

• Vasopressers
• 100 cc fluids (start low to avoid pulmonary edema)
• Lisinopril
• Antibiotics
• Source control (controlling infection itself)

Take Home Points:

• Sepsis = inflammatory defense against bacteria, defined by HR, RR, Temp, and white count. 
• BUN creatinine ratio >20 = possible pre-renal. Patient was around 30. He is being perfused poorly; there is nothing intrinsically wrong with the kidney. 
• Having low BP, high temp, HR and RR, nausea raises probability of infection. 
• Early goal directed therapy is treatment for sepsis. Sore throat, common cold can cause sepsis, but not necessarily make you sick. 
• Severe sepsis is end organ damage issue. Signs of severe sepsis are urine output (whether kidneys function), UTI went back up to the kidneys and caused back pain—> caused severe sepsis. 1) Give fluids. 2) Give pressors. 
• End organ damage caused by low cardiac output which is broken up into HR, BP, etc. HR was preload, anatropy (heart), then afterload. Shock = poor perfusion caused by heart not working (no pump to heart), preload issues (decreased blood, volume, vasodilation), and anaphylaxis/sepsis, increased afterload (resistance) is rare for really hypertensive people who can’t perfuse.
• Treat this with fluids (fill tank with fluid, press and make sure they are carrying enough hemoglobin (12 and higher good level), give something for anatropy.
• Fix perfusion on one end and control infection on the other.