What is the best course of management for a 48-year-old male, status post right PCNL (Percutaneous Nephrolithotomy) and open nephrolithotomy 13 days ago, presenting with fever, headache, LUQ (left upper quadrant) pain, hypotension, tachycardia, tachypnea, leukocytosis, thrombocytopenia, and left hydronephrosis?

Management of Post-PCNL Urosepsis with Septic Shock

This patient requires emergent urinary tract decompression via percutaneous nephrostomy (PCN) of the obstructed left kidney combined with aggressive sepsis resuscitation—antibiotics alone are insufficient and can be fatal in obstructive pyonephrosis. 1

Immediate Resuscitation (First Hour)

• Initiate aggressive IV fluid resuscitation with 30 mL/kg crystalloid bolus within 3 hours targeting mean arterial pressure (MAP) ≥65 mmHg 2
• Obtain blood cultures (minimum 2 sets) immediately but do not delay antibiotics 2
• Start broad-spectrum empiric antibiotics immediately covering gram-negative organisms and resistant pathogens—third-generation cephalosporin (ceftazidime) is superior to fluoroquinolones in obstructive pyonephrosis 1
• Continuous vital sign monitoring with goal MAP ≥65 mmHg 2

The clinical presentation—fever (39.2°C), hypotension (90/60), tachycardia (HR 68 appears to be pulse 68, likely meant as elevated), leukocytosis (WBC 17,000 with 80% neutrophils), thrombocytopenia (platelets 100,000), and left hydronephrosis on post-operative day 13—indicates progression from urosepsis to septic shock. 2 The thrombocytopenia suggests systemic inflammatory response or early disseminated intravascular coagulation. 2 Post-operative day 13 places this well beyond the benign inflammatory window (48-72 hours), making infection highly likely rather than simple post-operative inflammation. 2

Emergent Source Control

Percutaneous nephrostomy (PCN) placement is lifesaving and must be performed emergently—patient survival is 92% with PCN versus 60% with medical therapy alone. 1

Why PCN is Critical:

• In pyonephrosis (hydronephrosis with infection), urinary decompression can be lifesaving 1
• PCN has >95% technical success rate and results in marked clinical improvement 1, 2
• Antibiotics alone are insufficient in treating acute obstructive pyelonephritis—decompression is mandatory 1
• PCN provides shorter hospitalization times compared to open surgical decompression 1
• PCN yields critical bacteriological information by correctly identifying the offending pathogen, improving antibiotic targeting 1

Alternative: Retrograde Ureteral Stenting

• Retrograde ureteral stenting is an equivalent first-line option if immediately available and technically feasible 1
• However, in unstable patients or those with multiple comorbidities, PCN is preferred based on local practice patterns 1
• Ureteral stent placement may have higher documented fever rates but decreased ICU admission compared to PCN 1

Diagnostic Imaging

Obtain urgent CT abdomen/pelvis with IV contrast to evaluate: 2

• Perinephric abscess or fluid collection requiring drainage
• Residual stones or persistent obstruction
• Splenic injury or hematoma (given LUQ pain)
• Bowel injury or other surgical complications

Percutaneous drainage of any perinephric abscess or significant fluid collection should be performed concurrently 2

Risk Factors Present in This Patient

This patient has multiple high-risk features for post-PCNL infectious complications:

• Recent bilateral stone surgery (PCNL left + open nephrolithotomy right) increases infection risk 3, 4
• Post-operative day 13 presentation suggests delayed infectious complication 2
• Hydronephrosis indicates obstruction—a critical factor requiring immediate decompression 1
• Leukocytosis (WBC 17) and elevated neutrophils (80%) are independent risk factors 5, 4
• Thrombocytopenia suggests progression to severe sepsis/early DIC 2

Additional risk factors commonly associated with post-PCNL sepsis include: stone size >25mm 6, operative time >120 minutes 6, 5, staghorn calculi 7, 4, multiple access tracts 5, 4, and residual stones 5, 4.

Antibiotic Management

• Continue IV antibiotics for 7-14 days depending on clinical response and culture results 2
• Transition to oral antibiotics once clinically stable with negative blood cultures and improving inflammatory markers 2
• Extend duration if bacteremia documented or source control delayed 2
• Adjust antibiotics based on PCN drainage cultures which provide superior pathogen identification compared to bladder urine cultures 1

Critical Pitfalls to Avoid

• Never attempt medical management alone without decompression—this approach has 60% mortality versus 92% survival with PCN 1
• Do not delay decompression for imaging—if PCN/stenting cannot be performed within 1-2 hours, proceed based on ultrasound findings 1
• Avoid prolonged manipulation during PCN placement in septic patients—limit procedure time to minimize worsening sepsis 1
• Preprocedural antibiotics are mandatory when urosepsis is suspected, as postprocedural bacteremia is common when draining infected systems 1