Surgical source control in a patient with septic shock due to severe emphysematous pyelonephritis

[摘要] A 65-year-old woman presented with a 1-weekhistory of right flank pain and fatigue. On the dayof admission, she was found immobile at homeand was transported by ambulance. Her medicalhistory included diabetes mellitus and breast cancer10 years ago. At admission, vital signs included:Glasgow Coma Scale: E4V5M6, blood pressure77/55mm Hg, heart rate 120 beats/min, temperature 36.2°C, and respiratory rate 42/min. Physicalexamination revealed a mildly distended abdomenwith right flank and costovertebral angle tenderness. Blood tests showed white bleed cell count18.5x109/L, hemoglobin 11.7 × 10-1 g/L, platelet7.8×10-5/L, blood urea nitrogen 67.9mg/dL,creatinine 3.53mg/dL, sodium 124 mEq/L, potassium 3.7 mEq/L, chloride 84 mEq/L, prothrombintime-international normalized ratio 1.29, bloodglucose 543mg/dL and glycosylated hemoglobinA1c 12.1%. Blood gas analysis was significant formetabolic acidosis with pH 7.41, arterial oxygenpressure 101.6mm Hg, PaCO2 16.1mm Hg, bicarbonate 10.0 mEq/L, base excess 12.1 mEq/L, andlactic acid 3.43mmol/dL. Urinalysis showed whiteblood cell 3+ and occult blood 3+. CT scan of theabdomen revealed emphysematous changes in theright kidney (figure 1), and the diagnosis of rightemphysematous pyelonephritis (EPN) class 3B wasmade. She was admitted to the intensive care unit(ICU). After obtaining blood and urine cultures,meropenem and vancomycin were administeredintravenously. Resuscitation continued with intravenous fluids, vasopressors, and steroids according tosurviving sepsis guidelines, but her condition deteriorated. Six hours after admission, she was intubatedand required mechanical ventilation. A portableabdominal X-ray showed progression of emphysematous changes in the right kidney (figure 2).

[学科分类] 社会科学、人文和艺术（综合）

[关键词] sepsis;laparotomy;kidney