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Difficulty: Very hardUrologic Surgery

A 6262-year-old man is evaluated in the surgical intensive care unit for sudden clinical deterioration. Three days ago, he was admitted with septic shock secondary to an obstructing 1212-mm proximal left ureteral calculus. A left percutaneous nephrostomy tube was placed for urgent decompression, and empiric intravenous piperacillin-tazobactam was initiated. The patient initially stabilized and his leukocytosis improved. However, over the past 22 hours, the nephrostomy tube has stopped draining, and the patient has become confused and diaphoretic. His temperature is 39.4∘C39.4^\circ C (102.9∘F102.9^\circ F), blood pressure is 78/4578/45 mmHg, and pulse is 132132/min. Physical examination reveals a new, exquisitely tender and fluctuant swelling in the left flank. Blood and urine cultures from admission are currently growing *Escherichia coli* that is susceptible to ceftriaxone, trimethoprim-sulfamethoxazole, and ciprofloxacin. Which of the following is the most appropriate next step in the management of this patient?

  1. Perform emergent bedside ultrasonography and re-establish urinary tract drainageAnswer
  2. B
    Broaden antimicrobial therapy to intravenous meropenem and add vancomycin
  3. C
    Transport the patient to radiology for a contrast-enhanced computed tomography scan of the abdomen
  4. D
    Obtain a portable chest radiograph and a lower extremity venous Doppler ultrasound
  5. E
    File a formal incident report focusing on disciplinary action for the physician who placed the tube

Answer

The correct approach is to perform emergent bedside ultrasonography and re-establish urinary tract drainage.
This patient has developed recurrent septic shock secondary to the dislodgment of his percutaneous nephrostomy (PCN) tube. This is clinically evidenced by the sudden cessation of urine output from the drain, a new fluctuant flank mass, and cardiovascular collapse. The fundamental principle of managing sepsis in the setting of obstruction or an abscess is source control. Because the patient is severely hemodynamically unstable, transporting him to radiology for a CT scan or fluoroscopy is contraindicated. The most appropriate next step is to utilize bedside ultrasonography to confirm the perinephric collection and immediately re-establish drainage (either via a new percutaneous tract or repositioning over a wire if possible) while continuing aggressive intravenous fluid resuscitation and vasopressor support.

Step-by-Step Solution

1
Identify the cause of clinical deterioration.
The sudden cessation of nephrostomy tube drainage combined with new flank swelling and recurrent septic shock strongly indicates that the tube has dislodged into the perinephric space, leading to an infected urinoma or abscess.
Recognizing the loss of source control is critical for determining the next intervention.
2
Assess the patient's hemodynamic stability.
The patient is in severe shock with a blood pressure of 78/4578/45 mmHg and a heart rate of 132132/min.
Hemodynamic instability dictates where and how diagnostic and therapeutic interventions can safely be performed.
3
Select the appropriate intervention.
Bedside ultrasonography is chosen to confirm the collection, followed immediately by re-establishing percutaneous drainage.
Unstable patients cannot be safely transported to a CT scanner. Immediate source control (drainage) is the only definitive treatment for obstructive urologic sepsis.

Key Concept

Prioritization of bedside diagnostics and emergent source control in hemodynamically unstable patients with urologic surgical complications.
Estimated Time:1m 30s
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Urologic Surgery

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