Urosepsis

The obstruction is the diagnosis - Post-renal obstruction is one of the most common causes of urosepsis, and ultrasound identifies 93% of the usual contributors, including hydronephrosis and prostate abscess. Before induction, know whether this patient has an obstructed system and where it is. If nobody has imaged it, that is the question to ask.

Drainage is the operation - Foley placement for retention, a ureteral stent or percutaneous nephrostomy to bypass an obstructing calculus. Source control should be done as soon as possible, and the case should be short and minimal — the definitive stone or tumor procedure waits for another day. Set the anesthetic up for a brief decompression, not a full endourologic case.

Labs and cultures, but not at the cost of delay - Urinalysis with culture, blood cultures, CBC, comprehensive metabolic panel, and a lactate to show end-organ dysfunction. Draw them, but never hold the antibiotic waiting for them. Because severe sepsis impairs renal and hepatic clearance, get pharmacy involved on antibiotic dosing rather than assuming standard intervals.

Resuscitate before you induce - Initial crystalloid resuscitation is recommended at a minimum of 30 mL/kg, with early rather than late vasopressor support. Get that underway before induction. An anesthetic dropped on top of an untreated, vasodilated, volume-down patient is where these patients arrest.

Vasopressor plan - Norepinephrine is the first choice to hold a MAP above 65 mmHg, with epinephrine second and vasopressin third. On anyone already on pressors, have the infusion running and an arterial line planned before induction, not after.

Cut the induction dose - Whatever agent you choose, the dose is a fraction of normal, with a push-dose pressor drawn up in your hand. Positive-pressure ventilation on a vasodilated, volume-down patient will drop preload further.

Treat as a full stomach - Ileus, vomiting, and an obtunded patient are common here. Plan RSI.

Glucose - Tight glucose control is part of sepsis management. Check a glucose on arrival and keep checking it — an anesthetized patient will not tell you.

Endourology in an infected tract - Stone surgery in infected urine is the classic trigger for postoperative urosepsis. Keep operative time and irrigation pressure part of the conversation with the urologist, and do not be surprised by a patient who looks fine at the start of the case and vasodilated by the end.

Disposition - These patients are not extubated onto a regular ward. Book the ICU bed early and plan for continued vasopressor and antibiotic titration.

Urosepsis is sepsis whose source is the urinary tract — cystitis below, pyelonephritis above, prostatitis, or an infected obstructed kidney. Close to 25% of all sepsis cases originate in the urogenital tract. The recurring setup is infected urine that cannot drain: post-renal obstruction is one of the most common causes, typically an obstructing ureteral calculus, with the rest coming from urinary retention, indwelling catheters, prostate abscess, recurrent UTI, renal stones, and immunocompromised or instrumented tracts.

Once organisms reach the circulation the cascade is the usual one — pro-inflammatory and anti-inflammatory activation, monocytes, macrophages and neutrophils engaging endothelium through pathogen-recognition receptors, vasodilation, and end-organ dysfunction. Renal and hepatic impairment in severe sepsis slows antibiotic clearance.