■ Remember A (airway), B (breathing), C (circulation).
■ Administer 100% oxygen via a face mask.
4. OTHER INFECTIVE UROLOGICAL EMERGENCIES 47
■ Establish intravenous access with a wide-bore intravenous cannula, e.g., 16 or 18 gauge.
■ Start an intravenous infusion of crystalloid e.g., normal saline or colloid e.g., Gelofusin.
■ Catheterise the patient to monitor urine output.
■ Start empirical antibiotic therapy (see below). This should be adjusted later when cultures are available.
■ If there is septic shock, the patient needs to be transferred to the ICU. Inotropic support may be needed. Steroids may be used as adjunctive therapy in gram-negative infections. Naloxone may help revert endotoxic shock. This should all be done under the supervision of an intensivist.
■ Treat the underlying cause. Drain any obstruction and remove any foreign body. If there is a stone obstructing the ureter, then either ask the radiologist to insert a nephrostomy tube to relieve the obstruction or take the patient to the operating room and insert a JJ stent. Send any urine specimens obtained for microscopy and culture.
Empirical antibiotic treatment is the 'blind' use of antibiotics based on an educated guess of the most likely pathogen that has caused the sepsis. In urinary sepsis, the cause is often a gramnegative rod. Gram-negative aerobic rods include the enterobac-teria, e.g., E. coli, Klebsiella, Citrobacter, Proteus, and Serratia. The enterococci (gram-positive aerobic nonhaemolytic streptococci) may sometimes cause urosepsis. In urinary tract operations involving bowel, anaerobic bacteria may be the cause of urospe-sis and in wound infections staphylococci, e.g., staphylococcus aureus and staphylococcus epidermidis are the usual cause.
The recommendations for treatment of urosepsis include (Naber 2001):
■ A third-generation cephalosporin, e.g., cefotaxime IV, ceftriaxone IV. These are active against gram-negative bacteria, but less active against staphylococci and gram-positive bacteria. Ceftazidime also has activity against Pseudomonas aerugi-nosa. It is therefore important to get an urgent gram stain on any fluid sample sent to the laboratory. About 5% of patients who are allergic to penicillin are also allergic to cephalosporins, so enquire about penicillinallergy and consider alternative antibiotics.