CCS Case: Septic Shock — Urosepsis

Case: Septic Shock — Urosepsis

Clinical Setup

• Presentation: 78-year-old female from nursing facility with fever 39.2°C, altered mental status, BP 82/48, HR 124, foul-smelling urine, flank tenderness.
• Location: Emergency Department.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring, BP q15min.
   • 2 large-bore IVs, Normal saline 0.9% IV 30 mL/kg bolus stat.
   • Oxygen to keep SpO2 > 94%.
   • Foley catheter with hourly urine output monitoring.
2. Focused Exam (Minute 1–2):
   • Focused abdominal/flank exam (CVA tenderness), lung exam (rule out pneumonia source), skin exam (rash, wounds).
3. Diagnostics (Minute 2–5):
   • Blood cultures x2 BEFORE antibiotics, Urinalysis + urine culture stat.
   • CBC, BMP (lactate trend, creatinine), serum lactate stat, ABG, PT/INR, PTT.
   • CXR portable (rule out concurrent pneumonia).
4. Therapeutics (Minute 5–15):
   • Broad-spectrum IV antibiotics within 1 hour: e.g., Piperacillin-Tazobactam + Vancomycin (adjust per local protocol; add coverage per suspected source).
   • Repeat lactate in 2 hours; repeat BP check after fluid bolus.
   • If hypotensive after fluids: Norepinephrine IV infusion and transfer to ICU.
   • Advance clock in 15–30 min increments; re-examine vitals, mental status, urine output.
5. Disposition (Minute 15–20):
   • Admit to ICU (septic shock on pressors).
   • De-escalate antibiotics when cultures return; monitor creatinine and fluid balance.
6. Final 2 Minutes:
   • Counsel family on prognosis, goals of care, infection prevention, follow-up cultures.
   • Schedule infectious disease and primary care follow-up; document vaccination status (influenza, pneumococcal).