An 86-year-old Caucasian female had a history of high blood pressure and diabetes with chronic kidney disease. Gynecologic and obstetric history were gravida 2, para 2 (G2P2), with two healthy children. The onset of menopause was at the age of 51 years. She was a widow, lived alone, and was a former schoolteacher retired since the age of 65 years. She did not smoke or drink alcohol. Her medications were: perindopril (oral route) 4 mg once a day, metformin (oral route) 500 mg two times a day, and insulin glargine injection 100 units/mL, 16 IU once a day at the same time. She was hospitalized in our medical unit within the emergency department for pyelonephritis associated with a moderate deterioration of the serum creatinine from 114 μmol/L to 139 μmol/L (normal range 50–100 μmol/L). Her initial vital signs included RR of 19 breaths per minute, HR of 112 beats per minute with regular pulse, and blood pressure (BP) of 107/59 mmHg with mean arterial pressure (MAP) of 75 mmHg. Initial clinical examination of this patient revealed that she had a temperature of 38.9 °C with sweating, unilateral left flank pain, and nausea. Cardiovascular, pulmonary, and neurological examinations were normal. Laboratory investigations indicated a bacterial infection with procalcitonin of 0.56 µg/L and white blood cell count of 24.0 × 103/mm3 (normal range 4–10 × 103/mm3) including 21.6 × 103/mm3 neutrophils. Initial arterial lactate was 1.90 mmol/L. Other blood tests were within the reference range (Table 1). Urine dipstick test confirmed a urinary tract infection with positive dipstick hematuria, and leukocyte esterase and nitrite tests returned positive. The treatment consisted of intravenous administration of cefotaxime 1 g/8 hours antibiotic and 0.9% saline 500 mL over a period of 30 minutes and then 1000 mL/12 hours, and pain and fever management. HR was 91 beats per minute, blood pressure 135/79 mmHg (MAP 98 mmHg), and serum lactate 1.3 mmol/L after treatment. Remote continuous monitoring was used in the ward to monitor the patient in real time (Figure 1A) in addition to the nursing monitoring, which included the measurement of vital signs every 8 hours. Remote monitoring does not replace nursing monitoring, which also records the assessment of pain and other patient complaints as well as delivering care. By using a patch worn on the patient chest associated with an axillary temperature sensor, smart algorithms continuously process and analyze vital signs [6, 7]. The E-health technology aimed to generate targeted notifications of patient deterioration. The objective was to detect a possible deterioration of the vital signs in the time periods between the manual monitoring by the nurses in the hospital setting. In addition to regular monitoring on standard Personal Computer (PC) stations (Fig. 1B and C), surveillance was also conducted by iPad (Apple). iPads were attached to trolleys used by nurses, allowing them to continually monitor all patients while doing rounds (Fig. 1D). In the present case, the emergency nurse and physician received an alert by email and the Sensium application on 29 August 2018 at 12:56 pm indicating a sudden increase of HR from 115 to 140 beats per minute, an increased RR from 22 to 35 breaths per minute, and an elevated temperature of 39.6 °C (Fig. 2A and B). Computed tomography (CT) scan was carried out and found multiple foci of nephritis of the upper pole of the right kidney. No dilatation of the pyelocaliceal cavities or obstruction of the urinary excretory tract was seen (Fig. 3). Upon manual monitoring, clinical examination, and biological tests, sepsis was diagnosed on the basis of the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score calculation . SOFA was 6: Coma Glasgow Score (CGS) 14, BP 97/48 mmHg (MAP 64 mmHg), Arterial partial pressure of oxygen (PaO2) 76 mmHg and PaO2/The fraction of inspired oxygen (FiO2) 362, deterioration of the serum creatinine from 139 to 172 μmol/L, and platelet count 141,000/µL. There was no bilirubin abnormality. Therapeutic reinforcement was performed with oxygen therapy 2 L per minute because PaO2/FiO2 ratio was < 400; a single daily dose of amikacin 30 mg/kg (1800 mg intravenous injection over a period of 30 minutes) in addition to cefotaxime 2 g intravenous injection, 1 L of isotonic crystalloid 0.9% saline in 15 minutes because MAP was < 70 mmHg; and paracetamol 1 g intravenously. This treatment improved her clinical condition and reversed vital distress at 02:32 pm with HR of 112 beats per minute and RR of 22 breaths per minute (Fig. 2B and C). She was admitted to the intensive care unit. Blood culture and cytobacteriological examination of urine found Escherichia coli [106 colony-forming units (CFU)/mL] with established sensitivity to third-generation broad-spectrum bactericidal cephalosporin antibiotics (Table 2). Treatment with cefotaxime 6 g per day was continued at a dosage of 2 g/8 hours intravenously. Her vital signs stabilized within 2 days, and she returned to a lower acute ward: HR 90 beats per minute, RR 17 breaths per minute, Glasgow Coma Score (GCS) 15, MAP 87 mmHg, PaO2 91 mmHg, serum creatinine 116 μmol/L, and platelet count 183,000/µL. Antibiotic was changed at the fifth day for ciprofloxacin twice a day (every 12 hours) in the morning and evening, based on the antibiogram (Table 2). After 8 days of hospitalization, the patient was allowed to return home with treatment by ciprofloxacin twice a day (every 12 hours) in the morning and evening for a duration of 7 days. A follow-up of the patient was carried out at 7 days, which did not show any anomaly. No complications were observed by her general practitioner at 1 month, 6 months, and 1 year.
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