#Urosepsis - complicated UTI: 10 high-yield ICU pearls #004 Some colleagues hate the term “urosepsis.” I’m not going to die on that hill. I think we have more important things to worry about, like what to do when a crashing-and-burning patient arrives in our ICU from the ED, or returns from the OR, with urosepsis. Oops, I did it again! The antibiotics are running, the fluids are in, the MAP looks better... but the infected kidney may still be obstructed. We may have improved the numbers without fixing the problem. Here are my 10 high-yield pearls. At least I hope they’re worth remembering: 1. An infected, obstructed kidney is an emergency Think of it as an abscess that cannot drain. We give antibiotics, fluids, vasopressors. The blood pressure improves and we feel better. But the kidney is still infected and obstructed. Infected obstruction means urgent decompression. 2. No hydronephrosis doesn’t mean no obstruction Hydronephrosis may be minimal or even absent, particularly early in the course or in a severely dehydrated patient. Ultrasound can miss ureteral stones; noncontrast CT gives us a better look at their size, location, and associated obstruction. And don’t dismiss a stone because it’s tiny. Even a 1-2 mm stone in the ureter can obstruct an infected kidney and cause major trouble. It’s not the size of the stone. It’s where it is and what it’s obstructing. 3. A clean urinalysis doesn’t exclude an infected kidney Uncommon, but if you’ve been in the game as long as I have, you’ll probably see it. With complete ureteral obstruction, infected urine may be trapped above the stone while the bladder urine looks surprisingly clean! The opposite trap exists too: bacteriuria plus a stone doesn’t prove the urinary tract is the source. Keep looking for another one. Treat the patient, not the urine dipstick. 4. Source control cannot wait until morning A patient with sepsis from an infected, obstructed kidney needs drainage urgently. If they arrive in the middle of the night, this may mean calling urology or IR at 3:00 am. Nobody loves those calls, but sometimes they simply cannot wait. Even a relatively stable patient with suspected infected obstruction needs urgent assessment and a drainage plan. The clock matters. Unfortunately, it doesn’t care what time it is. 5. Stent or nephrostomy? The best one is the one that drains A ureteral stent drains internally from the renal pelvis to the bladder; a percutaneous nephrostomy drains the collecting system through the flank. Which is better? It depends: anatomy, bleeding risk, anesthesia, technical feasibility, local expertise, and availability. At 3:00 am, that last one suddenly matters a lot! Either approach can be difficult or fail. An impacted stone may be impossible to cross, and distorted anatomy can hide the ureteral orifice. Nephrostomy can be tricky with minimal dilation, difficult access, body habitus, or bleeding risk. Don’t debate the perfect technique. Have a rescue plan. 6. Nephrostomy often means prone. Plan the airway first Before sending a critically ill patient to IR, ask: Can they tolerate the position? Can IR do it supine-oblique in this patient? What happens if they deteriorate? Would securing the airway beforehand be safer? You don’t want to code your patient in the IR suite. Trust me on this one! Decide on the airway before the patient is face-down. 7. Antibiotics: look back before you look forward Get blood and urine cultures early, preferably before antibiotics, but never at the expense of delaying treatment in septic shock. In patients with recurrent UTIs, prior instrumentation, stents, or multiple admissions, I always want to know what grew last time, and the time before that. And to my anesthesiology friends: please don’t automatically give cefazolin (Ancef) to the patient coming for a stent exchange who has already had five admissions with MDR Acinetobacter and Pseudomonas. Check the old cultures. Yesterday’s microbiology may guide today’s antibiotics. 8. Decompression doesn’t always mean immediate improvement The patient goes for drainage and we expect things to turn around. Instead, they come back looking considerably worse. Sometimes this is progression of severe sepsis; bacteremia and manipulation of an infected collecting system may also contribute. Excessive irrigation or contrast injection can raise intrarenal pressure, another reason to be cautious. Source control is essential, but don’t be surprised if the patient gets worse before getting better. 9. Still septic after a stent? Question the drainage The antibiotics are in. The stent was placed. Yet the fever persists, pressor requirements are climbing, or organ dysfunction is worsening. Before blaming “sepsis,” ask: Is the stent where it should be? Has it migrated? Is the kidney actually draining? A KUB can check stent position; ultrasound or CT can look for persistent obstruction or another source. Sometimes it’s not that treatment needs more time. It’s that source control was never achieved. A stent in the procedure note doesn’t guarantee a drained kidney. 10. Drain the infection first. Deal with the stone later. The emergency procedure is about drainage, not winning the battle against the stone. Drain the kidney, treat the infection, stabilize the patient, then deal with the stone. And stents and nephrostomy tubes need a plan too: follow-up, exchange, or removal. We may be done with the ICU part of the story, but the patient isn’t necessarily done with the problem. Sometimes the most important thing in the ICU is recognizing when antibiotics are not enough. #foamed #foamcc