What is the management for post RIRS (Retrograde Intrarenal Surgery) septicaemic shock with a history of CLD (Chronic Liver Disease) and recent Dengue fever?

Management of Post-RIRS Septicemic Shock with Chronic Liver Disease and Recent Dengue Fever

Initiate immediate aggressive fluid resuscitation with at least 30 mL/kg of crystalloid solution within the first 3 hours, start broad-spectrum antibiotics within 1 hour, and urgently assess for urological source control while accounting for the patient's compromised hepatic function and recent dengue-related endothelial dysfunction. 1, 2

Immediate Resuscitation (First Hour)

Fluid Management

• Administer 30 mL/kg of crystalloid solution within the first 3 hours, using either balanced crystalloids or normal saline as first-line therapy 1, 2
• In the context of recent dengue fever, use colloid solutions cautiously as they may be beneficial in severe dengue shock syndrome (pulse pressure <10 mmHg), but crystalloids remain first-line in most situations 1
• Continue aggressive fluid administration for 24-48 hours, as septic patients often require more than 4 liters in the first 24 hours 1
• Monitor closely for fluid overload given the CLD background and potential for ascites development 1

Antimicrobial Therapy

• Administer broad-spectrum intravenous antibiotics within 1 hour of recognizing septic shock at adequate dosages 1, 2
• Choose empiric coverage based on:
  • Post-urological instrumentation (RIRS): Cover uropathogens including resistant Gram-negatives (ESBL producers, Pseudomonas)
  • Recent dengue infection: Consider secondary bacterial infections, particularly Staphylococcus aureus (including MRSA), as dengue causes endothelial dysfunction allowing bacterial tissue invasion 3, 4
  • CLD background: Account for altered drug metabolism and potential for spontaneous bacterial peritonitis organisms
• Add empiric antifungal coverage (echinocandin preferred) if the patient has risk factors: prolonged fever >5 days post-dengue, acute kidney injury, immunosuppression from liver disease, or prior broad-spectrum antibiotic exposure 1, 3, 4
• Obtain blood cultures (at least two sets) and urine cultures before antibiotics if this does not delay therapy 2

Source Control

• Identify and drain any urological source within 12 hours: assess for obstructed infected kidney, perinephric abscess, or retained stone fragments post-RIRS 1, 2
• Perform urgent imaging (ultrasound or CT if stable) to evaluate for hydronephrosis or fluid collections 1
• Remove or replace any ureteral stents placed during RIRS as they may be the infection source 1, 2
• Sample and culture any drained fluid with Gram stain and antibiogram 1

Hemodynamic Management

Vasopressor Therapy

• Initiate norepinephrine as first-choice vasopressor if hypotension persists despite adequate fluid resuscitation, targeting mean arterial pressure ≥65 mmHg 1, 5, 2, 6
• Use dopamine or epinephrine as alternatives in resource-limited settings or if norepinephrine is unavailable 1
• Add epinephrine if additional vasopressor support is needed 5, 2
• Measure arterial blood pressure and heart rate frequently in patients requiring vasopressors 1

Corticosteroids

• Administer hydrocortisone (up to 300 mg/day) or prednisolone (up to 75 mg/day) if the patient requires escalating vasopressor doses 1

Monitoring Endpoints

Target the following clinical indicators of adequate tissue perfusion 1:

• Normal capillary refill time (<2-3 seconds)
• Absence of skin mottling
• Warm, dry extremities with well-felt peripheral pulses
• Return to baseline mental status
• Urine output ≥0.5 mL/kg/hour (unless established renal failure)
• Normalize lactate levels as a marker of tissue hypoperfusion 1, 2

Special Considerations for CLD

Fluid and Hemodynamic Adjustments

• Perform large-volume paracentesis with intra-abdominal pressure measurement if tense ascites is present, as this can cause hemodynamic, renal, or respiratory compromise 1
• Use smaller fluid boluses with more frequent reassessment if there is evidence of cardiac dysfunction or portal hypertension 2
• Consider albumin supplementation when substantial crystalloid volumes are required, particularly given the hypoalbuminemia common in CLD 1

Antibiotic Modifications

• Adjust antibiotic dosing for hepatic dysfunction: avoid hepatotoxic agents when possible and monitor drug levels if available 1
• Provide full loading doses despite liver disease, then adjust maintenance dosing 1
• Cover for spontaneous bacterial peritonitis organisms (E. coli, Klebsiella, Streptococcus) if ascites is present, using third-generation cephalosporins or fluoroquinolones 1

Hepatic Support

• Consider N-acetylcysteine administration if acute-on-chronic liver failure develops, as case reports suggest benefit in dengue-related acute liver failure 7, 8, 9
• Monitor for hepatic encephalopathy and use lactulose or rifaximin if overt encephalopathy develops 1

Special Considerations for Recent Dengue

Secondary Infection Risk

• Maintain high suspicion for concurrent bacteremia, particularly Staphylococcus aureus, as dengue causes immune dysregulation and defective immune cell function 3
• Monitor for infective endocarditis if fever persists beyond 5 days despite appropriate antibiotics, especially with acute kidney injury 3
• Consider disseminated candidiasis if fever persists, as dengue-induced intestinal damage can cause fungal translocation 4

Thrombotic Complications

• Assess for deep vein thrombosis if there are clinical signs, as dengue interferes with anticoagulant pathways and activates procoagulant factors 3
• Balance bleeding risk from thrombocytopenia against thrombotic risk from endothelial activation

Renal Management

• Use continuous veno-venous hemodialysis (CVVHD) if available for acute kidney injury, as this allows better fluid management during the reabsorption phase of dengue recovery and prevents pulmonary edema 7
• Monitor for fluid reabsorption during dengue recovery phase (typically days 5-7), which can precipitate heart failure if not managed carefully 7

Respiratory Support

• Apply oxygen to achieve saturation >90%, or administer empirically if pulse oximetry unavailable 1
• Position patient semi-recumbent (head of bed 30-45°) unless unconscious, then use lateral position with clear airway 1
• Consider non-invasive ventilation for dyspnea or persistent hypoxemia despite oxygen therapy if staff is adequately trained 1

Ongoing Management

Daily Reassessment

• Reassess antimicrobial regimen daily for de-escalation once pathogen identification and sensitivities are available 1, 2
• Use procalcitonin levels to guide antibiotic discontinuation if available 1
• Continuously monitor for signs of fluid overload, particularly during dengue recovery phase 7

Avoid Common Pitfalls

• Do not use hydroxyethyl starches for fluid resuscitation, as they increase acute kidney injury and mortality risk 2
• Do not rely on CVP alone to guide fluid therapy; use dynamic measures of fluid responsiveness when available 1, 5
• Do not delay antibiotics for culture results; obtain cultures quickly but do not postpone treatment 2
• Do not overlook fungal infections in this high-risk patient with multiple predisposing factors 1, 4
• Do not perform large-volume paracentesis if spontaneous bacterial peritonitis is suspected until after antibiotic initiation 1