Fever and Borderline Hypotension on Day 10 After a T6 Injury
A 29-year-old woman sustained a T6 AIS A injury in a fall from a horse and underwent T4-T8 fusion 10 days ago. She now has a temperature of 38.7 C, heart rate 118, blood pressure 92/58 (baseline 110/70), respiratory rate 22, and SpO2 94% on room air. Her urethral catheter drains cloudy urine. She reports no dysuria or flank pain, but she has no sensation below T6. The abdomen is soft. Breath sounds are decreased at both bases with crackles. There is a 2 cm area of erythema over the sacrum that does not blanch. White blood cell count is 14.2 and lactate is 1.4. Urinalysis shows more than 100 white cells and many bacteria, nitrite negative. The admitting team plans to start ceftriaxone for UTI and discharge her in 3 days.
1. What is the most likely source of fever, and what is your differential? How does the urinalysis change your management?
Read the worked answer
The most likely source is respiratory: basilar crackles and a weak cough from thoracic injury make atelectasis or pneumonia the leading cause in the first two weeks. The differential includes catheter-associated UTI, deep vein thrombosis or pulmonary embolism, infected pressure injury, an occult intra-abdominal source (she cannot feel pain), drug fever, and, less likely at day 10, heterotopic ossification. The urinalysis shows pyuria and bacteriuria, which are common with an indwelling catheter and do not by themselves diagnose UTI; a negative nitrite is not reassuring. Do not start antibiotics based on the urinalysis. Obtain a urine culture after replacing the catheter if possible, blood cultures, chest radiograph and consider CT chest, lower-extremity ultrasound, and a careful skin examination. Review medications. If she is stable, observe and treat the identified source; if she is septic, start broad-spectrum antibiotics after cultures.
2. The urine culture grows more than 100,000 CFU/mL E. coli. The team wants 7 days of antibiotics. What do you recommend and why?
Read the worked answer
Treating a catheterized patient with a positive culture but no symptoms is treatment of asymptomatic bacteriuria and is discouraged: it selects resistant organisms and does not improve outcomes. However, she is febrile and has no clear alternative source yet, and fever in SCI can be the only sign of UTI. Base the decision on the whole picture. If chest imaging is negative and she remains febrile with the same organism, a 5-7 day culture-guided course is reasonable. If a respiratory source is found, treat that and do not treat the urine. Replace the catheter, avoid unnecessary fluoroquinolones, and consider whether the catheter can be removed. Cloudy urine is not a criterion, and a single positive culture is not a diagnosis.
3. Four hours later she is confused, blood pressure is 78/45, and heart rate is 132. Outline your first-hour management.
Read the worked answer
Assume sepsis. Call for help, give oxygen, and monitor continuously. Place two large-bore IVs, obtain blood cultures before antibiotics, and give broad-spectrum antibiotics within 1 hour. Give a 30 mL/kg crystalloid bolus with reassessment, and start norepinephrine if the mean arterial pressure remains below 65 despite fluids. Replace the urinary catheter and send a culture, obtain a chest radiograph, and repeat lactate. In a T6 injury, baseline blood pressure is low, so use MAP targets and clinical perfusion rather than a single cuff reading. Look for a noxious trigger that could cause autonomic instability, such as a distended bladder, fecal impaction, or pressure injury, but do not delay antibiotics. If bradycardia develops, give atropine. Reassess for a respiratory source and consider whether the antibiotics cover the likely pathogens.