The test is not the disease

When I was a trainee intern we had a patient on my general medical placement present with 2 days of right arm swelling and tenderness, with dilated superficial veins over her arm and upper chest. Her d-dimer was normal. She had an ultrasound of the upper limbs looking for a DVT. This was negative. With a negative d-dimer and USS we were all ready to discharge the patient home (who was otherwise well), however the consultant, a mentor of mine, insisted on a CT venogram. We all rolled our eyes. Eye rolling turned into eye widening as the scan showed the subclavian vein thrombosis we had all been missing. Continue reading

You’re taking the piss

Urinary tract infections are the scapegoat of the medical world. They make us lose our common sense, because once you find something that is easy to treat, you stop looking for anything else. This is termed satisfaction of search.

Let us look at two examples where a positive urine sample may lead the ward house officer astray, related to the domain of surgery.

Firstly, you have a patient who is POD4 after an anterior resection. You are called because they have become febrile. There is no obvious source on examination. You take cultures, and the mid stream urine comes back with a high number of white cells. You start the patient on cefuroxime for a presumed UTI. This is a frequent occurrence.

Unfortunately this decision neglects the basic rule of general surgery. This rule states that the main differentials in a febrile patient after abdominal surgery are as follows; anastomotic leak, anastomotic leak,  anastomotic leak and also anastomotic leak.

“But the urine is positive!”

Unfortunately pyuria is common in intraabdominal sepsis, presumably due to the infection rubbing up against the wall of the bladder and causing inflammation. The rate of sterile pyuria in appendicitis and diverticulitis for example can be anywhere from 25% to 70-80%, depending what literature you read (1,2).

This phenomenon is not even confined to intra-abdominal infection. 30% of patients presenting with pneumonia, sepsis, intra-abdominal infection, or enteritis have pyuria (3). Of these urine samples, only 30% were culture positive. Note that culture positivity does not imply a UTI- there will be a significant proportion of asymptomatic bacteriuria.

The second situation will be when you are not on general surgery, but convincing the surgical registrar to review your patient who has abdominal pain and a clinical presentation concerning for something surgical.

“But the urine is positive, why don’t you just treat the UTI?”

Take home message? Pyuria is common in patients with other serious sources of infection and you should remind yourself and others of this.

Till next time….

  1. Ther Adv Urol. 2015 Oct; 7(5): 295–298. Sterile pyuria: a forgotten entity. Sanchia Goonewardene and Raj Persad
  2. 09 Sterile Pyuria an Indication of Acute Appendicitis in Children. S. Lewis1, C. St. Laurent1, A. Ruiz-Elizalde1 1University Of Oklahoma College Of Medicine,Oklahoma City, OK, USA
  3. Sterile Pyuria in Patients Admitted to the Hospital With Infections Outside of the Urinary Tract. Jared B. Hooker, MS2, James W. Mold, MD, MPH, and Satish Kumar. JABFM March 2013:97-103

 

Supine masking of hypotension

tburg

Today’s post regards a common pitfall regarding the assessment of the hypotensive patient. Unfortunately, it will be based on anecdote rather than literature, but hopefully you won’t find the underlying assumptions too controversial.

Often you are called to the bedside of a patient with a hypotensive episode. You arrive to find them flattened on the bed, sometimes in the Trendelenburg position. You take stock of the situation and find the airway to be intact, the patient fully responsive, with warm peripheries and a good strong peripheral pulse. They are breathing comfortably. A blood pressure is taken and this is 110/70. The other vitals are normal as is the rest of the examination.

It is easy to conclude that the blood pressure has normalised and that this was therefore a self- resolving period of hypotension, most likely postural or vasovagal. What is important to remember is that, if you leave at this point, you have left the patient in a highly unnatural position. People don’t live their lives supine, nor indeed in Trendelenburg, and often their previous blood pressure recording taken in hospital will be with them sitting up. It is easy to gloss over this fact as you only arrive after the fact and therefore tend to only ever see the patient supine.

Before being reassured that the blood pressure is normal you must make sure it is normal in the sitting position. If they are sat up and now the blood pressure is 85/40, you clearly have an ongoing problem. Even the most posturally fragile old patients should maintain a normal blood pressure while sitting.

I have certainly ignored my own rule multiple times and it is extremely easy to do so because the human mind tends to only see what is there in front of you. Also, given the multitude of calls for abnormal vital signs, we latch onto any indication that the patient is actually OK and doesn’t need intervention. A few times when I ignored this rule I was later called for sustained hypotension (of course after they had been sat up) which turned out to be proper pathology.

The first of many lessons that you always need to take into account what we have done to the patient when making your assessment!