What is the management approach for a patient in septic shock with an obstructing ureteral stone (kidney stone) causing impaired renal function and potentially hypotension?

From the Guidelines

In a patient with septic shock due to an obstructing ureteral stone, immediate intervention is required with two parallel priorities: treating the septic shock and relieving the urinary obstruction. For septic shock management, start with aggressive fluid resuscitation using crystalloids (30 ml/kg within the first 3 hours) as recommended by 1, followed by vasopressors if the patient remains hypotensive. Norepinephrine should be used as the first-line vasopressor at 0.05-0.5 mcg/kg/min as suggested by 2, 3. Administer broad-spectrum antibiotics within the first hour, such as piperacillin-tazobactam 4.5g IV q6h or meropenem 1g IV q8h plus vancomycin dosed by weight. For the obstructing stone, urgent decompression is necessary via retrograde ureteral stent placement or percutaneous nephrostomy, with the choice depending on available expertise and patient stability, as discussed in 4. The nephrostomy may be preferred in unstable patients as it can be performed at bedside under ultrasound guidance. Blood cultures should be obtained before antibiotic administration, and the patient requires ICU-level care with continuous monitoring. The combination of sepsis and obstruction creates a urologic emergency because the blocked urinary system serves as a reservoir for infection, perpetuating the septic state, and only by addressing both components simultaneously can the patient be stabilized effectively. Key considerations include:

• Aggressive fluid resuscitation and vasopressor use to manage septic shock
• Urgent relief of the urinary obstruction
• Broad-spectrum antibiotic administration
• ICU-level care for close monitoring and management of potential complications. Given the most recent and highest quality evidence from 4, percutaneous nephrostomy is a viable option for urgent decompression in patients with obstructing ureteral stones and septic shock, offering a potentially lifesaving intervention in critically ill patients.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Septic Shock with Obstructing Ureteral Stone

• The primary goal in managing septic shock due to an obstructing ureteral stone is to relieve the obstruction and treat the underlying infection 5, 6.
• Percutaneous nephrostomy (PCN) is often considered the standard treatment for sepsis associated with ureteral stone obstruction 5.
• However, retrograde ureteroscopy (URS) can be a safe and effective alternative in select clinical situations, particularly when performed by skilled endourologists 5.
• URS has been shown to be successful in 94.6% of patients with ureteral stone-related sepsis, with a low rate of complications and no anesthesia-related morbidities or postoperative deaths 5.

Treatment Approaches

• Treatment of the infected stone typically involves complete stone removal, and kidney stones that obstruct the urinary tract and cause obstructive pyelonephritis are considered a urologic emergency 7.
• The use of ureteral stenting and percutaneous nephrostomy can help to relieve the obstruction and manage the infection 6, 7.
• Antibiotic therapy is also crucial in the management of septic shock, and the choice of antibiotic should be guided by the results of bacterial culture and sensitivity testing 6, 8.

Predicting Septic Shock

• The quick sequential organ failure assessment (qSOFA) score has been shown to be a more accurate predictor of septic shock than the systemic inflammatory response syndrome (SIRS) criteria in patients with obstructing ureteral stones and presumed infections 9.
• The qSOFA score had a higher specificity and area under the curve (AUC) for predicting postoperative septic shock compared to SIRS criteria 9.

Antibiotic Dosing

• The dose of antibiotics, such as piperacillin-tazobactam, should not be reduced in patients with septic shock, as this can be associated with worsened clinical outcomes 8.
• Clinicians should be vigilant to avoid antibiotic dose reduction in early phase septic shock, and instead aim to use the standard dose to ensure adequate coverage and improve patient outcomes 8.