Emergency Management of Unexpected Life-Threatening Septic Shock in a Patient Undergoing Ureteroscopic Stone Removal

We present a case of life-threatening septic shock undergoing ureteroscopic stone removal in the operation theatre just after the surgery. Patient was symptomatically diagnosed on the operation table and intensively managed to stabilize quickly without wasting time and later it was confirmed by investigations that it was a septic shock resulted due to Gram negative bacilli E-coli.


Introduction
In spite of higher levels of advancement in surgeries related to the urinary tract there are few unexpected complications which are quite difficult to predict or prevent. Despite careful preoperative preparation of patients, there is persistent risk of urosepsis in patients undergoing surgery for ureteric stones. This case was encountered during surgery in our hospital and it's a very rare case, of which very few are reported worldwide and probably the first case of its kind reported from India.

Case Report
A 44 years old man with left side flank pain got admitted in our hospital. He was an old case of renal as well as ureteric stone with history of surgery for stone removal two years back. He had no prior history of Type II Diabetes, hypertension or any other chronic disease. Results of all physical examinations were completely normal.
The patient was planned for ureteroscopic stone removal and all necessary investigations were done according to protocol which is shown in Table 1.  Urine analysis showed specific gravity 1.015, PH of 6.0, white blood cell count was 3 to 5 cells/hpf, red blood cell count was 10 to 15 cells/hpf and the culture of morning midstream urine showed presence of Gram negative bacilli E-coli. On CT IVU left kidney showed multiple tiny calculi in minor calices with mild hydronephrosis. Left ureter showed mild dilatation with a calculus of size 8 × 8 mm in its distal segment 1.5 cm proximal to left UVJ.

Laboratory investigations Parameters
Prior to surgery the patient was started with intramuscular antibiotic amikacin sulphate single dose and oral ciprofloxacin 500 mg tablets for five days. After keeping the patient nil per oral for 6 h ureteroscopic stone removal was performed under spinal anaesthesia with 0.5% Bupivacaine (heavy) and the time taken for surgical procedure was 50 min during which period his vitals remained completely normal.
Just 10 min later the patient suddenly had restlessness with shivering. On physical examination he had tachycardia (120 beats/ min) and hypotension (90/60 mmhg). Respiratory rate was more than 30/min. Despite of treatment with ephedrine 6 mg boluses intermittently, hypotension deteriorated gradually and septic shock was suspected. Immediately another intravenous access was obtained with an 18G cannula and aggressive fluid management with crystalloids was started. Arterial blood was obtained from right hand radial artery and the report is shown in Table 2.  and immediately Noradrenaline drip was started at 0.1 µgm/kg/min with a microdrip infusion set. A dose of Imipenem 500 mg combined with Cilastatin 500 mg was administered empirically.

Laboratory investigations
Gradually blood pressure was maintained at 110/64 mmhg and pulse rate at 90 beats/min. Oxygen saturation was maintained above 96% and subsequently the patient was shifted to intensive care unit for observation and further management. In the intensive care unit the patient was managed conservatively for two days without any use of vasopressors or mechanical ventilation. The lactate level came down to 1 mmol/L on the very next day of his admission to intensive care unit. On laboratory investigation his total WBC count was elevated to 21,400 cells/µl with differential count showing 96% of neutrophils. His C-reactive protein level was 296.4 mg/l. On culture blood as well as urine showed E-coli infection. Hence it was confirmed to be a case of septic shock.

Discussion
Sepsis is a systemic deleterious host response to infection that is associated with high rates of unfavourable outcomes. It can result from bacteria, viruses, fungi, or parasites, or it can develop in non-infectious intraabdominal incidents such as severe trauma, pneumonia, pancreatitis, and other incidents such as urinary system infection. Mortality rates for severe sepsis and septic shock have been reported to be as high as 28-41% [1,2]. In a significant proportion of these cases, the source of infection is the urinary tract (severe sepsis: 9%; septic shock: 31%) [3]. In the event of persistent hypotension after initial fluid administration (MAP<65 mmHg) or if initial lactate was ≥ 4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table 1.   7 Re-measure lactate if initial lactate elevated. When a midstream urine sample shows evidence of infection, the operation should be postponed until a sterile urine sample is achieved. Despite this, the patient is still potentially at risk of a life-threatening systemic infection [4]. Kamei et al. [5] revealed that thrombocytopenia and a positive blood culture were independent risk factors for septic shock in cases of acute obstructive pyelonephritis requiring emergency drainage. The inability to definitively determine the site of infection and to obtain positive blood cultures, however, should not preclude treating patients with severe sepsis (Table 3). In 20-30% of septic patients, a definite site of infection is not determined [6,7]. Similarly, blood cultures are positive in only approximately 30-35% [6][7][8]. Sepsis has a complicated pathology, and it is not yet fully understood because it has a variety of clinical and physiopathological symptoms [9].
In this case the patient was treated with adequate fluid management, broad spectrum antibiotics, vasopressors and MAP>65 were maintained. There was no evidence of severe hydronephrosis and the time taken for the surgery was also short, still a life threatening septic shock emerged unexpectedly in the operation theatre.