key: cord-0977607-48ii6ttu
authors: Qu, Jiachun; Xu, Kui
title: Case report of rescue of a patient with COVID‐19 and shock after holmium laser lithotripsy
date: 2022-04-08
journal: Int J Urol Nurs
DOI: 10.1111/ijun.12319
sha: 711555f362a53d7caa189a4049857f2898eb9f08
doc_id: 977607
cord_uid: 48ii6ttu

Lithotripsy is the primary form of treatment for ureteral calculus. According to clinical data, ureteroscopic lithotripsy (URSL) is characterized by better efficacy, a lower risk of complications, and a quicker postoperative recovery, when compared with open surgery. However, elderly patients often have a variety of chronic diseases that can directly or indirectly influence intraoperative care and postoperative recovery. It is important that medical staff closely observe changes in the postoperative condition of patients and provide them with the best quality care. In order to control the progression of disease and reduce mortality rates, it is very important to promptly eliminate the cause of shock, supplement blood volume, and correct cardiovascular disorders. During the pandemic caused by coronavirus disease 2019 (COVID‐19), there has been a significant focus on management, predominantly operating rooms but also intensive care units (ICUs), to ensure that hospitals can provide prompt and effective diagnosis and treatment for every patient with COVID‐19 and also prevent the spread of the virus and guarantee the safety of medical staff. During surgery on patients suspected of having COVID‐19, it is important that specific personnel take control of the designated work and implement three strict levels of protection to prevent the transmission of the virus by air, droplets, and personal contact. Attention should be paid to the transfer of patients, the protection of medical staff, the management and control of negative pressure operation rooms, and postoperative treatment, thereby ensuring the safety of patients and medical staff. In this case report, we describe the nursing experience of rescuing a patient with COVID‐19 who developed septic shock following flexible ureteroscopic holmium laser lithotripsy. The causes of septic shock were subsequently examined to inform a new protective strategy for rescuing patients with COVID‐19 in the operating room and ICU, and to prevent and control cross‐infection with the virus during surgery.

ications (Lianhua Qingwen capsules, ibuprofen suspension, and Moxifloxacin tablets); these medications gradually reduced her body temperature back to normal. On the 15th of March, she was diagnosed with mild hydronephrosis by CT urography and an intravenous pyelogram (IVP) was carried out prior to surgery. CT urography identified a calculus in the right lower ureter and right kidney ( Figure 2 ) and IVP showing mild hydronephrosis in the right kidney ( Figure 3) . The results of a midstream urine drug sensitivity test and bacterial culture F I G U R E 1 On March 12, 2020, a KUB showed obvious nonradiolucent calculus shadows in the right renal region and the right lower ureter, with maximum diameter of approximately 21 mm  11 mm. A right ureteral calculus was therefore suspected. KUB, kidney-ureter-bladder F I G U R E 2 On March 15, CT urography identified a calculus in the right lower ureter and right kidney revealed that there was no bacterial growth, while the results arising from chest X-ray and electrocardiography were all normal. Physical examination revealed no abnormalities in the heart and lungs, a flat and soft abdomen with no rebound pain or tenderness, symmetrical costal spinal angles, percussion tenderness in the right renal region but not in the left region, no edema in either of the lower extremities, and that the two renal regions or the upper pubic region were not full.

Following discussion, the urologists decided to perform flexible ureteroscopic holmium laser lithotripsy on the 22nd March with 1 g of imipenem and cilastatin sodium infused as a preventive antiinfective therapy 30 min prior to surgery. To avoid cross-infection, the patient wore a disposable surgical mask and entered the isolated operating room through a separate channel. Negative pressure (<À5 Pa) was turned on in the operation room 30 min prior to surgery.

The patient entered the operating room at 10:05 AM and tracheal intubation was performed by an anesthesiologist according to threelevels of protection. The patient received laryngeal mask airway ventilation under general anaesthesia. The circulating nurse removed items from the operating room not related to the surgery and hung an isolation card 'COVID-19' on the door of the operating room. Once the operation began, the surgeon conducted retrograde catheterization of the affected ureter and observed that urine in the affected ureter was abnormally turbid and that there was a calculus wrapped within layers of polyps. The polyps were removed using biopsy forceps, followed by lithotripsy with a 1 mm ballistic lithotripsy probe under a pressure of 0.2 mPa.

The door of the operating room was kept closed during the operation, and negative pressure in the room was maintained. The patient suffered from minor blood loss during the operation, which lasted for 48 min. A double-J tube was then inserted for drainage and the operation was successfully completed at 10:55 AM. Following completion, the patient was transferred to a recovery room for observation. A urologist wearing a double layer of sterile gloves sealed the ureteral calculus specimen in a double-layer specimen bag marked with 'COVID-19'. The specimen was then placed in a closed container and sent to the Pathology Department for testing. A circulating nurse disinfected the unmanned operating room with an ultra-low-volume spray of peracetic acid. At 11:15 AM, after waking and extubation, the patient was transferred to the ICU and given care and close observation by a specialist nurse. Following surgery, penicillin was infused intravenously as anti-infective therapy. At 14:30 on the same day, the patient had a pale complexion, dysphoria, and skin clamminess. At infused 250 ml of 5% sodium bicarbonate to correct metabolic acidosis, while 10 mg of norepinephrine injection was added to a 5% glucose injection and then continuously pumped into the patient using a micro-pump to enhance vascular activity and maintain hemodynamic stability. Following these treatments, the patient's vital signs gradually became stable. At 16:10, her blood pressure rose to 100/60 mmHg and the mean arterial pressure, central venous pressure, body temperature, heart rate, and 24-h urinary output were >70 mmHg, 11 cm H 2 O, <38 C, <100 beats/min, and >3000 ml, respectively. The urine also became clear. By 20:30, the vasopressor drugs were gradually withdrawn, and antibiotic administration stopped after the patient's body temperature and routine haematology tests became completely normal. At this time, the patient had received negative blood and urinary culture results. When the patient sweated heavily, the sweat was wiped off promptly and the bedding and clothing replaced in order to keep the skin dry (the flow sheet of rescue of septic shock is shown in Figure 4 ). From the 24th of March to discharge, 10 mg of dexamethasone was administered, and 20 mg of furosemide was injected intravenously every day to promote urination and improve the symptoms of systemic poisoning. On the 25th of March, routine blood and urinary results had returned to normal and on the 27th of March, the patient was considered to be cured and was discharged, although the ureteral stent was retained. The patient was asked to return for reexamination after 1 month of home quarantine. Thirty-five days after the operation, the patient's body temperature was normal, breathing sounds in both lungs were clear, and there was no sign of respiratory discomfort. The results of a swab nucleic acid test were negative and CT of the urinary tract was normal. Therefore, we removed the ureteral stent.

After the patient was discharged, a surface disinfection cleaner With the continuous development of urology technology, ureteral stent implantation has been extensively utilized; this new technique is capable of relieving inflammation and maintaining unobstructed ureters. However, urinary tract infection following ureteral stent implantation is a major cause of unplanned hospital visits, reduces a patient's quality of life and increases treatment costs; however, this also affects a patient's subsequent recovery. Furthermore, the drug resistance of bacteria has increased over recent years, largely because of the irra-the occurrence of postoperative urinary tract infection. Our analysis indicated that the reduction of calculus formation and postoperative calculus residuals helps to reduce the risk of urinary tract infection following ureteral stent implantation. Furthermore, Escherichia coli are the main form of pathogenic bacteria that cause urinary tract infections after ureteral stent implantation in urological patients, and therefore require particular attention. 5 Therefore, we should take active preventive measures to control underlying diseases and infections prior to surgery in patients with high-risk factors, improve related preoperative examinations and review routine urinary data after surgery, identify pathogenic bacteria in patients, and select appropriate antibiotics for long-term treatment.

Single or multiple organ dysfunction can develop quickly when septic shock occurs simultaneously, thus resulting in a high mortality rate.

The patient described herein had COVID-19 with only mild respiratory symptoms, Once septic shock is diagnosed, the perfusion of important organs should be improved as soon as possible, fluid resuscitation should be performed within 6 h, and the following four anti-infective and anti-shock therapies should be performed as soon as possible. First, a reduction in effective blood volume is the most important pathophysiological change in septic shock; therefore, early fluid resuscitation is the key to treating the condition. After shock occurs, the patient should be infused quickly with sufficient colloidal or crystalloid fluids; those with anaemia should also be infused with red blood cells and plasma, so that the central venous pressure and mean arterial pressure reaches 8-12 and >65 mmHg, respectively. During these infusions, the condition of the patient should be monitored comprehensively, including vital signs, central venous pressure, urinary output (an objective quantitative index for shock), laboratory test results, and clinical efficacy. Septic shock is often accompanied by acidosis; therefore, the patient needs to be supplemented with a sodium bicarbonate solution. Second, under the premise of providing an effective circulating blood volume and correcting for acidosis, the patient should be treated with dopamine or norepinephrine. Third, anti-infection therapy is the key to treatment after septic shock. Once septic shock occurs, sensitive and effective antibiotics should be administered as soon as possible, and blood and urinary bacterial cultures and drug sensitivity tests should be performed. High-efficiency and broad-spectrum antibacterial drugs are recommended for this anti-infective therapy prior to obtaining final test results. Fourth, the functionality of the target organs should be protected to prevent cerebral edema or heart failure. In the present case, the reaction to shock was very severe, making it difficult to rescue the patient. Therefore, nurses should make correct and decisive judgements, take quick actions, perform skilled operations, and pay close attention to changes in cardiopulmonary function and vital signs. The patient should also actively receive anti-infective therapy in addition to ensuring shock is prevented by the infusion of fluids.

Septic shock is a severe complication of flexible ureteroscopic holmium laser lithotripsy and represents a major threat to the health and safety of patients. The treatment of septic shock is dominated by effective anti-infection therapy, fluid resuscitation, the administration of vasoactive drugs and glucocorticoids, and the provision of supportive treatment. Early and effective anti-infective therapy is the key to correcting shock and avoiding death. Nurses should have a detailed and thorough knowledge of the disease and be able to detect, prevent and promptly manage changes in the patient's condition as early as possible, thereby reducing the risk of death.

In this case report, our patient was diagnosed with COVID-19 complicated by septic shock that was characterized by its extremely rapid development and extreme difficulty with regards to treatment and care.

The medical staff were at high risk of exposure to the COVID-19 virus.

There are key lessons that arose from this case report. First, standardized emergency nursing procedures and rapid and accurate emergency nursing techniques are the basis for guaranteeing the success of rescue.

Nurses in the operating room and ICU should receive regular training so that their busy rescue work can be carried out in an orderly manner and to ensure that targeted rescue nursing can be provided based on variations in the specific clinical condition of the patient. Septic shock is a severe condition and is characterized by its rapid progression and changes over time. Therefore, nurses must be able to respond rapidly, have a diverse knowledge of first aid, possess skilled rescue techniques and the ability to observe disease, be familiar with the rescue process and the use of ECG monitoring and ventilators, and actively take first aid measures, thereby gaining time for the rescue of patients.

Following a series of symptomatic treatment strategies and meticulous care, the vital signs of the patient described in this case report tended to be stable and her urinary output gradually returned to normal. It was therefore considered that the patient was cured and accordingly she was discharged. Close observation, early detection, and the introduction of appropriate anti-shock therapy are all key factors for the diagnosis and treatment of septic shock in this patient. Nurses in the operating room and ICU performed routine midstream urine bacterial culture and drug sensitivity tests prior to surgery. During surgery, the monitoring of vital signs was strengthened, the perfusion pressure was timely and reasonably adjusted based on the patient's condition, and aseptic techniques were implemented rigorously. Following surgery, appropriate antibiotics were administered for anti-infection therapy so that lithotripsy could be performed successfully, thus resulting in the patient being cured and discharged from hospital.

Committee of the First Affiliated Hospital of Soochow University and ethical approval number is 2021SE-256-73. In addition to the approval of the ethics committee, this retrospective study also obtained the written informed consent, including consent to publish from the patient and family members. Written informed consent was voluntarily obtained from individual or guardian participants who have been informed of the study including any of the benefits and risks involved.

Written informed consent for publication was obtained from all participants and patients.

The datasets used in the current study are available from the corresponding author on reasonable request.

https://orcid.org/0000-0002-5176-8453

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The prevalence of urinary tract infection following flexible ureterenoscopy and the associated risk factors

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Biomarkers in sepsis

Burden of urolithiasis: trends in prevalence, treatments, and costs

Case report of rescue of a patient with COVID-19 and shock after holmium laser lithotripsy

We are particularly grateful to Mr. Kui Xu for his valuable suggestions and discussions. I would also like to express my gratitude to EditSprings for