Hematuria & urosepsis

willi irawan
Hematuria
Presence of blood in the urine
Microscopic : 3 rbc/HPF

Gross : visible

Frightened by sudden onset

Any degree should never be ignored
Malignancy ??
History
To target the subsequent diagnostic
evaluation efficiently

Gross or microscopic
At what time (beginning, during or end)
Associated with pain
Passing clots ( specific shape)
 Should be regarded as a symptom of
malignancy until proved otherwise

Demands urologic examination

Gross hematuria (cystoscopy)

The most common cause of gross hematuria

in a patient older than 50 years is bladder
cancer
Causes
Malignancy
Calculus
UTI
Trauma
BPH
Approach
Thorough history
Urinary symptoms
Recent history (trauma)
Systemic features (fever, weight loss)
Co morbidity
Drug history
Occupation
Family history
Physical examination
Vital signs

Abdominal
Palpable mass
Rectal examination
investigations
Blood count, urinalysis

Sonography

CT scan
Urosepsis
Is caused by the invasion, from a focus in the
urinary tract, of pathogenic or commensal
microorganisms, prompting a complex
response by the synthesis of endogenous
mediators responsible for the clinical
phenomena

Progress, increased riskof death

Etiology
Gram-negative bacteria

Gram-positive bacteria
Pathophysiology
Poor perfusion of skin and internal organs w/
reduced arterial-venous oxygen gradient by by-
passing the capillaries via multiple shunts,
accumulation of lactate
Activation of the complement and blood
coagulation cascades
Activation af B and T lymphocytes
Activation of neutrophils (increasing chemotaxis
and adhesiveness)
Increased capillary permeability
 Accumulation of neutrophils in the lungs
where they release proteases and oxygen
radicals
Myocardial depression, hypotension
Accelerated apoptosis of lymphocytes and
gastrointestinal epithelial cells
DIC
Impairment and failure of hepatic, renal,and
pulmonary functions
Classification
Criterion I
definitive evidence of infection (positive
hemoculture)or clinically suspected infection
Criterion II : Systemic inflammatory response
syndrome (SIRS)
38C or 36 C
90 beats/min
20 breaths/min
PaCO2 32 mmHg
4.000 WBC or 12.000 WBC
Immature neutrophils > 10 %
 Criterion III : MODS
90 mmHg systolic or 70 mmHG MAP
<0,5 ml/kg of body weight/h
PaO2 5 mmHg
Platelet count < 80.000 or 50 % decrease from the
highest value over 3 days
Metabolic acidosis
Brain
Diagnostic procedures
Increased sedimentation rate
Increased C-reactive protein
Increased leucocyte counts
Thrombocytopenia
Hyperbilirubinimia
Increased creatinine level
Proteinuria
Alkalosis respiratory
Biomarkers of sepsis (cytokines, procalcitonin)
Microbiology
At least two blood culture at the same time

Best taken during vthe rise in body temp

When antimicrobial has started,blood drawn

before repeated antibiotic
Further diagnostic
Focal source of infection must be sought
carefully

Microbiological analysis : purulent secretion,

urine, abscesspus
Therapy
Goals of therapy
Hemodynamics
Oxygen saturation
Organ perfusion
Organ function
Antimicrobial
sanitization
Therapy
Should be immediately transferred to the ICU
Volume replacement
Controlled and assisted ventilation
Vasopressors
Urine excretion
Antimicrobial therapy
Removal of the infectious focus