Emergency Department Urosepsis and Abdominal Imaging

Abstract

Background: Sepsis is an inflammatory response syndrome caused by infection, often resulting in decreased tissue perfusion and organ dysfunction. Since the advent of early goal‐directed therapy (EGDT) and improving non‐EGDT protocolized treatment, sepsis‐associated mortality has decreased markedly. Urosepsis confers mortality of 26‐30%. No protocols exist outlining appropriate use of imaging in uroseptic ED patients. Objectives: Our objective was to retrospectively evaluate uroseptic ED patients who underwent abdominal CT or US ordered by an ED provider, quantifying those requiring an emergent surgical consultation and underwent a procedure or surgery. Methods: We identified patients older than 17 years of age from January 2009 through December 2012 with an ICD‐9 code for urinary obstruction or sepsis and an ICD‐9 code for urinary infection or calculus. Patients also must have undergone CT or US ordered by an ED provider (N=1142). We re‐reviewed each patient urinalysis (UA) to ensure it was equivocal or positive for infection, then analyzed if a patient satisfied two or more SIRS criteria. Since urosepsis can be secondary to bacteremia, we also reviewed for the presence of a positive blood culture(s) to ensure that the urosepsis itself was the primary etiology and eliminating this potential confounding factor. Results: Of the 1142 patients, 77 were excluded for having a negative UA, 167 were excluded for having less than two SIRS criteria, 320 were excluded for having positive blood culture(s) and 32 were excluded for incomplete data. 546 patients underwent review of the CT or US findings to determine the percentage who required emergent surgical consultation and the percentage who underwent a procedure or surgery. Of the 546 patients, 47% (256/546) had imaging results requiring emergency surgical consultation. 35% (189/546) underwent a procedure or surgery. An additional five patients were recommended to undergo surgery but declined. Conclusion: This retrospective descriptive study reveals that a 47% of our uroseptic population who underwent CT or US in the ED required emergent surgical consultation and 36% received a recommendation to undergo procedure or surgery. Our findings underscore the importance in performing a prospective randomized controlled trial to further study imaging in urosepsis. Limitations include that this is a retrospective study with a selection bias.