Urosepsis: Pathogenesis and Clinical Manifestation
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This article discusses the pathogenesis and clinical manifestation of urosepsis, a severe infection of the urinary tract accompanied by systemic inflammatory response syndrome. It explores the risk factors, diagnosis, and nursing strategies for managing urosepsis.
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Running Head: UROSEPSIS1 UROSEPSIS Name Date Institution
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UROSEPSIS2 Urinary Tract infection Pathogenesis in relation to Clinical Manifestation Sepsis refer to a complex inflammatory response of a host to an infection. Urosepsis is therefore a severe infection of the urinary tract accompanied by systemic inflammatory response syndrome (Kalra and Raizada 2009). The CDC reports that urinary tract infections are the most common bacterial infections. One of the risk factors for UTIs is age. For instance, Mr Kirkman’s age, for instance, puts him at risk of developing urinary tract infections. A urinary tract infection starts when the bacterial colonization of the bladder (Porat and Kesler, 2018). The infection sometimes ascends through the ureters to the kidneys. The most common precursor of urosepsis us complicate UTI infection, which can be defined as an infection in a patient whose structural and functional system have an abnormality (Kalra and Raizada 2009). After infection with the pathogen, the body’s response determines development of sepsis and its severity. The pathogen’s proteins then interact with the proteins of the body triggering an immune response. The immune response leads to an increase in neutrophils which subsequently causes production of bactericidal substances and formation of edema from increased permeability of endothelial cells (Craft et al, 2015). Afterwards, the anti-inflammatory response causes suppression of the immune system. Lifestyle behaviors like smoking and heavy drinking, as in the case of Mr. Kirkman, suppress the immune system, making the body more susceptible to infection. In elder patients, the typical UTI manifestations may not be present or may be vague and replaced by findings like worsening mental state (Brusch, 2018) Some causes of UTIs include presence of urinary catheters and prosthetics, and other infections like epididymitis, pyelonephritis and cystitis. UTIs are more common in women but it
UROSEPSIS3 is speculated that they are more chronic in men (Dreger et al, 2015). Diagnosis of UTIs includes laboratory analysis of full blood count and urinalysis coupled with the signs and symptoms. Laboratory results of Mr. Kirkman show that his hemoglobin, red blood cells, platelets and packed cell volume and platelets were within normal ranges. However, his white blood cells were elevated which can be attributed to the underlying inflammatory process (Craft et al, 2015). Systemic inflammation is usually evidenced by high body temperatures, tachycardia, respiratory alkalosis with PaCO2 of less than 32mmHg and elevated white blood cells (Kalra and Raizada, 2009). Presentation of urinary tract infections is dependent on several factors and how they affect the immunity. In Mr. Kirkman’s case, his drinking and smoking might have exacerbated his illness as his history reveals a previous UTI infection. Levels of creatinine and urea were elevated indicating abnormal functioning of the kidneys. In addition, his electrolytes levels were also elevated. Sodium was 148mmol/l, Mg2+levels were 0.82mmol/, Potassium was 5.2mmol/l and CL-was 111mmol/l. these tests indicate the functionality of the urinary system. Elevated electrolytes, creatinine and urea are a result of abnormal ultrafiltration which causes elevated urine excretion as a result of bacteria in the urinary tract (Wagenlehner et al, 2013). Bacteria in the urinary tract cause activation of the complement and innate immune systems that lead to a pro-inflammatory reaction that includes both neutrophils and macrophages. Bactericidal substances are then produced as a result of increased neutrophils. Subsequent stimulation of B and T lymphocytes occurs producing more cellular immune reaction which is amplified by secondary mediators (Craft et al, 2015). This process leads to degradation of muscular proteins and antibody synthesis. The endothelial cells then produce the platelet
UROSEPSIS4 activating factor and nitric oxide, which causes hypotension by reducing vessel tone. Damaged endothelial cells have increased permeability which results in edema. However, like Mr. Kirkman’s, the initial pro-inflammatory phase is survived by most patients. however, a counter-regulatory response causes immunosuppression in the patient. Sepsis does not only affect the immune system. It also activates the complement system and affects coagulation and fibrinolysis. However, Mr. Kirkman’s laboratory tests on coagulation are all within normal ranges. Other systems affected during the inflammatory response include endocrine and autonomic systems. Nursing strategy Early administration of Intravenous antibiotics to treat the infection and relieve symptoms of urosepsis. These symptoms include high blood pressure, increased temperature, increased heart rate and low abdominal pain. Administration of antibiotics would relieve these symptoms and treat the source of infection (Hill, Hall and Glew, 2017). This must however be coupled with fluid resuscitation improves the patient’s chances of surviving. According to Brown and Semler (2019), fluid resuscitation in patients with sepsis reduced mortality rates. However, after initial resuscitation, care should be taken to avoid too much fluids which put the patient at risk of edema and subsequent organ dysfunction. A new study found the use of balanced crystalloid provided better outcomes than use of Saline. However, research should be undertaken to determine the dosage, rate and composition of intravenous fluid that is optimal for management of sepsis and septic shock (Brown and Semler, 2019). ABG analysis
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UROSEPSIS5 Arterial Blood Gases determine blood acidity and measure the amount of oxygen and carbon dioxide in the arterial blood to aid in diagnosis of critically ill patients. Partial Pressure of Oxygen (PaO2) measures oxygen pressure in the blood. Mr. Kirkman’s PaO2 is slightly below normal range which may explain Mr. Kirkmans inability to speak well as his brain is not receiving enough blood. Lower Ph indicates acidemia and low PCO2 causes respiratory alkalosis, which is a compensatory process for metabolic acidosis (White et al, 2018). Elevated lactate levels as in Mr. Kirkman’s case are associated with sepsis and septic shock. High levels indicate organ dysfunction. The increase sed levels of lactate can be attributed to impaired tissue oxygenation due to reduced delivery of oxygen to tissues. This leads to an increase in anerobic metabolism (Bonsall, 2017). Mr Kirkman’s bicarbonate levels were also below normal range which causes the patient to suffer metabolic acidosis. HCO3 depletion is as a result of renal disease, in this case the Urinary tract infection. Some symptoms associated with metabolic acidosis include tachycardia and confusion, both which are evident signs exhibited by Mr. Kirkman. The base excess deficit of the patient is -6, which is an indication of lactic acidosis and shock in the patient. The base excess shows the amount of base in comparison with acids present.
UROSEPSIS6 References Brown R and Semler M. (2019). Fluid management and sepsis.Journal of intensive care medicine.34 (5) Pp 364-373 Porat A and Kesler S. (2018).Urosepsis. Stat Pearls Publishing. Kalra O. and Raizada A. (2009). Approach to a patient with Urosepsis.Journal of global infectious diseases.1(1) Pp 57-63 Dreger. M, Degener S, Nehad P., Wobker G and Roth S. (2015). Urosepsis- Etiology, Diagnosis and Treatment.Deutsches Ärzteblatt Internationa.112: 837-848 Wagenlehner F, Lchte stern C, Rolfes C, Mayer K, Uhle F, Weidner W and Weigand M. (2013). Diagnosis and management of urosepsis.International journal of urology. 20(10) Pp 963-970 White, H. D., Vazquez-Sandoval, A., Quiroga, P. F., Song, J., Jones, S. F., & Arroliga, A. C. (2018). Utility of venous blood gases in severe sepsis and septic shock.Proceedings (Baylor University. Medical Center),31(3), 269–275. Brusch J. (2018). Urinary Tract infections in males differential diagnosis. Retrieved from https://emedicine.medscape.com/article/231574-differential#1
UROSEPSIS7 Bonsall l. (2017). Elevated Lactate-Not just a marker for sepsis and septic shock.Nursng center. Retreived fromhttps://www.nursingcenter.com/ncblog/march-2017/elevated-lactate- %E2%80%93-not-just-a-marker-for-sepsis-an Bullock S, and Manias, S.(2017).Fundamentals of pharmacology(8th ed.). Melbourne. Craft, J., Gordon, C., Heuther, S., McCance, K., Brashers, V., & Rote, N. (2015).Understanding pathophysiology(2nd ed.). Chatswood: Elsevier. Hill, R., Glew, h., Hal., H . (2017).Fundamentals of nursing and midwifery : A person-centered approach to care(Third Australian and new Zealand edition). North Ryde: Walters Kluwer