Orthopaedic Surgery: Urinary infection may be avoided with a simple indwelling catheter
Case Summary:
A 93-year-old man—alert and actively mobile, living with his son—fell backwards down 5 steps and fractured his left neck of femur (NOF) and his left upper humerus. He was on warfarin and had known comorbidities of a mechanical mitral valve replacement and atrial fibrillation. He was admitted to hospital the same day but found to be over-coagulated (international normalised ratio [INR] 4.5), which delayed the planned treatment of fracture fixation for several days. The over-coagulation problem was dealt with very effectively (INR 1.4 preop) but not before the patient had developed a large thigh haematoma and low haemoglobin (Hb) (64 g/L). He was given several units of packed red blood cells before surgery. All screening blood tests were essentially normal. By the time of operation (4 days post-admission) his Hb was 84 g/L. It was noted during preoperative work-up that he had episodes of urinary incontinence, suspected to be arising from bladder neck obstruction. This was managed in the ward with absorbent peri-pads.
An intramedullary nail was appropriately and expediently inserted without incident under spinal anaesthetic to effectively treat the NOF fracture. It was planned to fix the fractured left upper humerus some 7 to 10 days later. It is noted in the history that a urinary catheter was in situ at the time of surgery, but the following day the notes record: ‘no catheter is present’. No reason for the catheter removal was recorded. Overflow incontinence continued from that date onwards and was managed with pads and condom drainage.
The patient made good postoperative progress but continued bleeding into the thigh, requiring further blood transfusions over the following week. Hb stablised at around 85 g/L and he remained alert and was eating and drinking and able to sit out of bed. His anticoagulation cover was effectively maintained with Clexane 40mmg daily.
He became acutely unwell some 10 days post-surgery with signs of toxaemia, anaemia (Hb 57 g/L) and a high white cell count, combined with elevated C-reactive protein (CRP) (269 mg/L) and suddenly elevated serum creatinine (130 µmol/L). A urinary infection was suspected and Proteus mirabilis was cultured from the urine. Intravenous ceftriaxone was commenced 12 days post-surgery. He also had further blood transfusions to return Hb to 85 g/L. It was decided to abandon the planned fixation of his humeral fracture and continue conservative treatment using a shoulder/humeral splint. His toxaemia settled, but the urea, serum creatine and CRP levels remained elevated, in keeping with compromised renal function. He was able to tolerate food and fluids and sit out of bed with some discomfort. Warfarin was slowly recommenced.
At 05:25, 21 days post-surgery, the patient was asleep, with the history noting he was haemodynamically stable with peripheral oxygen saturation (SPO2) of 92%. One hour later, he was found not rousable, clammy and deceased. A cardiac event was postulated as the cause.
Discussion:
Postmortem found a large wound haematoma and a distended bladder with 1,300 ml cloudy urine, in addition to marked prostatic enlargement and diffuse infiltration of high-grade prostatic carcinoma, hydroureters, hydronephrosis and nephrosclerosis. The lungs were congested and bilateral acute bronchopneumonia was evident. The mechanical mitral valve was uncomplicated. The cause of death was listed as: ‘urosepsis complicating bladder outlet obstruction in the setting of a surgically repaired fractured NOF and the contributing factor of valvular heart disease’.
Clinical Lessons:
The medical and nursing care, decision-making and documentation in this case appeared quite satisfactory overall. However, it would appear that a simple, indwelling urinary catheter in this patient of considerable risk would have avoided the urinary stasis/retention risks and obstruction, which caused the severe infection that ultimately had a major role in contributing to postoperative death. This would appear to be an underutilised or overlooked option for the elderly male population undergoing surgery.
Disclaimer:
Please note that these cases are edited from ANZASM first- or second-line assessments that have been generated by expert surgeons in the field. Any recommendations relate to these cases as they were presented.
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