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To Discharge Or Not — Sepsis In The ED October 5, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , trackback
A 45-year-old man with hypertension and prostate cancer in remission presents complaining of 3 days of burning with urination, fevers, and chills. His vital signs are: heart rate, 110 beats/min; respiratory rate, 20 breaths/ min; blood pressure, 130/90 mm Hg; SpO2, 98% on room air; and temperature, 38.4°C (101.2°F). He is alert and fully oriented. His physical exam reveals mild suprapubic tenderness without rebound or guarding and bilateral costovertebral angle tenderness. Lab findings include a WBC count of 18,000 with 5% bands, a creatinine of 1.5 mg/dL, a platelet count of 130 x 103/mm3, 80 WBCs on urinalysis with positive nitrite and leukocyte esterase, and a serum lactate of 1.2 mmol/L. After receiving ibuprofen and a fluid bolus, the patient feels better and states, “I need to go get my dog!” The nurse asks you if she can remove the IV for the patient to be discharged, which sounds reasonable, but something worries you…
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What do you do next?
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Comments»

1. Michael Joo - October 5, 2018

Patient meets sepsis criteria in a setting of complicated pyelonephritis with end organ dysfunction (AKI) possibly due to obstructive uropathy as a sequelae of past or recurrent prostate CA. Admit

2. Bruce Gleason - October 5, 2018

Admit – discuss the risks in his particular case in regards to sepsis with acute renal insufficiency, have his nurse or call case management to come assist in finding solution to care for his dog. Should he insist on leaving inspite if efforts to convince him to stay, would try to get him to return to the ED immediately after making sure a care plan was in place for his dog, and would have him sign AMA document.

3. Allyson - October 5, 2018

Keeping the patient for a complicated UTI likely pyelonephritis-complicated as the patient possibly has abnormal physiology 2/2 his prostate CA- is what I would recommend to the patient. He also has a fever, so likely pyelonephritis. SIRS + Source = sepsis. He should stay. He needs cultures and parental abx.

4. Walter L Novey - October 5, 2018

This is a classic situation often encountered by ED docs. To use the vernacular expression – it’s a case of “horses and zebras.” If you discharge without any further testing, you have to make the assumption that all the findings are explained by pyelonephritis (the horse). Problem is that he could have pyelonephritis + some other process (the zebra) driving his symptoms and abnormal labs (infectious most likely). I would admit, observe overnight, treat with antibiotics and order a CT abdomen and pelvis with IV contrast.

5. Hany - October 5, 2018

It would be catastropic to discharge this patient!
He is clearly having pyelonephritis, leukocytosis, elevated serum creatinin. He needs IV antibiotics for 2-3 days, blood culture, IV fluids and monitoring his kidney function and clinical progression

6. Deborah Fisher - October 5, 2018

Admit, meets sepsis criteria, probable pyelonephritis.

7. Taylor - October 5, 2018

To briefly summarize, we have an immunocompromised patient with prostate cancer present with leukocytosis, bandemia, and bilateral CVA tenderness. Clinically this is bilateral pyelonephritis. Now, the patient wants to leave, however, I would have a site down conversation and explain to him the risks of leaving, regardless of him feeling better. This case would be an AMA or a hopefully patient can be convinced to stay. I would CT abdomen/pelvis with IV contrast. This could be any number of things besides ascending UTi, ranging from obstructive uropathy to emphysematous pyelitis/pyelonephritis. He needs IV fluids and potentially double gram negative coverage with Rocephin/Gent. Maybe he will agree to stay for at least a day?:)

8. Candace M Moore - October 5, 2018

POCUS- because why not? And then probably admit with a more clear picture

9. Ugo Gallo - October 5, 2018

Need more information. Would like to know what stage and last treatment. What is patient’s baseline creatinine and labs. Need to evaluate for outflow obstruction since he has bilateral CVA tenderness, which is not consistent with peylonephritis. Bedside ultrasound of bladder and kidneys would be helpful. Patient meets criteria for sepsis. Sepsis does not necessarily meet criteria for admission. Would meet criteria for observation status. Does he have any antibiotic allergies? Does he have history of prior urologic infection? If so cultural results and sensitivity. This would impact decision if out patient vs inpatient treatment. Would obtain urine culture; blood cultures are not indicated based on information given. Based on information could treat with dose of rocephin or ciprofloxin oral since the area of the curve is comparable to an IV dose with close out patient followup and discussion with urologist if no evidence of obstruction on ultrasound and Cr is base line. Otherwise, would recommend observation status vs full admission.

10. Bruce Oran, DO, FACEP - October 5, 2018

Patient needs imaging, blood cultures, await urine culture, and monitoring. Would treat with IV abx and admit to observation unit for further monitoring.

Advise patient he would be making a grave error by signing out and with his permission discuss with his health proxy. Putting him in observation unit might give him a greater sense of control while being able to complete the work-up.

11. Dustin O - October 5, 2018

Work up for sepsis(blood cultures procalcitinin CT etc.)with probably a DRE add a PSA( just to entice the internist). Call and serenade the internist, BAM, hes admitted.

I know I could have written a book like the others on here. Write a bunch of questions with dialogue blah blah blah.

12. Leno Congtang - October 5, 2018

This is America .let him go

13. James Derby - October 5, 2018

ADMIT PTN ON IV ZOSYN AS HE MEETS CRITERIA FOR SEPSIS. I WOULD ALSO GIVE 30CC/KG IVF NS BOLUS INITIALLY AND KEEP CLOSE EYE ON PTN. GRAM NEGATIVE SEPSIS CAN BE TRICKY AND ALTHOUGH HEMODYNAMICALLY STABLE NOW MAY DECOMPENSATE AT ANY TIME. I WOULD ALSO GET BLOOD AND URINE CULTURES, OF COURSE.

14. Ben - October 5, 2018

I think Ugo had it right. Doesn’t necessarily mean he has to be admitted. If the information isn’t available then err on the side of safety and admit. Definitely have a discussion of risks of leaving and return precautions and treat with oral antibiotics even if leaving AMA.

15. C Schwartz - October 5, 2018

Have the patient leave AMA and return only if he brings his dog with him , Then patient may be admitted for sepsis type work up including imaging, IV antibiotics, and likely urology consultation

16. Tarcylio - October 5, 2018

I will get a arterial blood gas. If there was a metabolic acidosis I would admit this pacient. By the way, if this ABG was normal, I would get the vital signs. If stable, discharge him with ATB and follow-up

17. Brian Collins - October 5, 2018

sign out AMA, or admit.

18. Sri Banala - October 5, 2018

1) Send Blood and urine cultures
2) Ceftriaxone 1g IV stat
3) 0.9% saline 1000 ml bolus
4) CT abdomen and pelvis with contrast
5) Depending on the CT – consult urology
6) Admit

19. agzidd@gmail.com - October 5, 2018

Patient meets criteria for severe sepsis. Likely prostatitis. Send blood clx, IV abx to cover for gram neg, admit.

20. Dennis Allin - October 5, 2018

He passes qsofa but the question of whether this is a bump in his creatinine and thus a sign of organ dysfunction along with a relative thrombocytopenia. With his history of prostate cancer and tachycardia it would be wise to use ultrasound to look for an obstructive uropathy, administer fluids, and give the first dose of antibiotics parenteraly. If he insists on taking care of his dog, which people frequently do, then give his fluids and antibiotics along with POCUS before he goes and tell him to come right back for recheck

21. Annie Nunley PA-C - October 5, 2018

Admit for Sepsis and complicated UTI in setting of Prostate CA (in remission). Needs IV abx and social services referral to help find a way to care for the dog (obtain local resources for dog care). Needs full septic workup including blood and urine cultures and second lactic within 6 hrs of first one. IV of NS at 30ml/kg unless CHF or some other contraindication for full fluid resuscitation. DVT prophylaxis is needed with hx of CA. GI prophylaxis needs to be considered. Obtain US Renal. Contact his oncologist. Repeat CBC, CMP in the morning. Urology consult if not responding to treatment. Offer nicotine patch if smoker.
If he refuses admit, will need to sign out AMA.

22. Micelle Jo Haydel - October 5, 2018

Admit: patient is relatively hypotensive b/c he has a hx of HTN. He is septic.

23. Yatoli - October 6, 2018

The pts dog puts him on alertness despite his sickness.it seems if the dog goes missing,it might caurse multiple erruptions.therefore the dog should be brought next to him as ED reviews his therapy assap.

24. Yatoli - October 6, 2018

In summery,the ED should be urgently called upon to facilitate the dogs presence which might be causing (obsessive hypertension),admit,start mgt;iv bolus ns 0.5ltrs+1grm ceftriaxone as the dog is availed.review the pt 30mins after he has sociolised and reassured his dog.take baseline test ie; repeat the above tests to rule out any changes to determine his discharge.

25. Bridget - October 6, 2018

Treat as sepsis, start abx for pyelonephritis (and check his prostate if he still has one, may be prostatitis), ensure no e/o obstruction, consider CT versus ultrasound for e/o obstruction. If patient’s cancer is in remission, creatinine and BP at baseline, normalized heart rate, tolerating PO and able to return for good 24-hr follow-up he may be a candidate for discharge, otherwise it’s AMA or convince him to stay at least for observation. Urine cx’s.

26. rachael Kinuthia - October 7, 2018

Patient has costovertebral tenderness suggestive of complicated UTI. His creatinine is elevated which is likely due to acute kidney injury. In view of this findings it will be prudent to admit for Intravenous antibiotics and close monitoring to see the trend of his renal function over the next few days and intervene if needed.

27. Sadaf - October 7, 2018

Prostatitis
IV antibiotics
Admit

28. Dr Ganesh Jadhav - October 11, 2018

Please admit this patient because he may have Pyelonephritis.

29. Christine Smith - October 11, 2018

Definitely treat as Sepsis. Send the fire dept to his house to check the dog or some good samaritan. He should have gotten Ceftriaxone when he walked in the door based on his vitals and hx.

30. Ruvini - October 15, 2018

He is in sepsis
Follow surviving sepsis guidelines

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