Acute and Critical Care

Case Report

Infection/Surgery
Refractory Septic Shock Treated with Nephrectomy under the Support of Extracorporeal Membrane Oxygenation: Young Kun Lee, Jeong Am Ryu, Jeong Hoon Yang, Chi-Min Park, Gee Young Suh, Kyeongman Jeon, Chi Ryang Chung; Korean J Crit Care Med. 2015;30(3):176-179. Published online August 31, 2015; DOI: https://doi.org/10.4266/kjccm.2015.30.3.176

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Abstract PDF: Conventional medical therapies have not been very successful in treating adults with refractory septic shock. The effects of direct hemoperfusion using polymyxin B and veno-arterial extracorporeal membrane oxygenation (ECMO) for refractory septic shock remain uncertain. A 66-year-old man was admitted to the emergency department and suffered from sepsis-induced hemodynamic collapse. For hemodynamic improvement, we performed direct hemoperfusion using polymyxin B. Computed tomography scan of this patient revealed emphysematous pyelonephritis (EPN), for which he underwent emergent nephrectomy with veno-arterial ECMO support. To the best of our knowledge, this is the first report of successful treatment of EPN with refractory septic shock using polymyxin B hemoperfusion and nephrectomy under the support of ECMO.

Original Articles

Analysis of Kidney Computed Tomographic Findings in Patients with Acute Pyelonephritis and Septic Shock: Soonseong Kwon, Sangchan Jin, Wooik Choi, Sungjin Kim; Korean J Crit Care Med. 2013;28(4):272-279.; DOI: https://doi.org/10.4266/kjccm.2013.28.4.272

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Abstract PDF: BACKGROUND
Clinical findings, medical history and laboratory findings in patients with acute pyelonephritis are insufficient to predict the occurrence of septic shock and to assess its severity and prognosis. Early imaging may not only aid in diagnosing acute pyelonephritis, but also help in assessing the risk factors associated with septic shock.
METHODS
In this retrospective study, we reviewed the medical records and collected the data of 200 patients from January to December, 2011. All patients were over 18 years old; showed symptoms of fever, chills, muscle pain and flank pain; demonstrated more than 10 white blood cells in urinalysis; and were diagnosed with acute pyelonephritis after computed tomography (CT) scan. Patients were classified into two groups: patients with septic shock (group 1) and patients without septic shock (group 2), and the clinical, laboratory and CT findings of the two groups were then compared.
RESULTS
Out of all 200 patients, there were 32 patients (16%) who had acute pyelonephritis with septic shock. The acute pyelonephritis with septic shock group (group 1) showed increased bacteremia compared with the other group (53.1% vs. 24.4%, p = 0.002). Laboratory findings showed that group 1 patients had higher serum creatinine (1.67 +/- 1.03 mg/dl vs. 1.14 +/- 0.98 mg/dl, p = 0.022) and hsCRP (8.36 +/- 5.29 mg/dl vs. 5.27 +/- 3.53 mg/dl, p = 0.000) than group 2 patients. The findings of kidney CT showed statistically significant differences in global renal enlargement (31.3% vs. 18.7%, p = 0.005), pelvicalyceal wall thickening (37.5% vs. 13.1%, p = 0.005) and poor excretion of contrast (25% vs. 2.4%, p = 0.000). The results of the logistic regression test showed that there were significant differences in bacteremia serum creatinine, C-reactive protein, pelvicalyceal wall thickening and poor excretion of contrast.
CONCLUSIONS
Computed tomography can predict the possibility of septic shock by identifying the range of renal lesions in patients with acute pyelonephritis. It can therefore allow initial aggressive treatment that can contribute to decreases in mortality and morbidity in patients with acute pyelonephritis.

Clinical Feature and Prognostic Factors of Emphysematous Pyelonephritis: Won Soek Yang, Won Young Kim, Chang Hwan Sohn, Dong Woo Seo, Jae Ho Lee, Won Kim, Kyoung Soo Lim; Korean J Crit Care Med. 2012;27(2):89-93.; DOI: https://doi.org/10.4266/kjccm.2012.27.2.89

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1 Crossref

Abstract PDF

BACKGROUND
Emphysematous pyelonephritis (EPN) is a rare and potentially life-threatening condition that requires prompt evaluation and management. However, its clinical presentation and outcomes vary widely. This study was conducted to ascertain the clinical features and prognostic factors regarding EPN.
METHODS
All patients diagnosed with EPN radiologically and treated at the emergency department in the university-affiliated, tertiary-referral center, from January 1999 to December 2009 were evaluated. The patients' demographic and clinical characteristics, computed tomographic findings, treatment, and outcomes were analyzed retrospectively.
RESULTS
Overall 14 patients diagnosed with EPN were admitted. There were 12 females and 2 males. A history of diabetes was found in 12 (85.7%) patients and was the most common comorbidity. The chief complaint among patients was flank pain (42.9%). Severe sepsis or septic shock was noted in 10 (71.4%) patients. Thirteen cases had unilateral involvement and one case had bilateral involvement. More than half of patients had Escherichia.coli in culture. Mean serum levels of HbA1c, creatinine, C-reactive protein (CRP) were 9.4 +/- 2.7, 2.4 +/- 1.4 mg/dl, and 22.4 +/- 13.1 mg/dl. Eight (57.1%) patients received antibiotic treatment alone and four (28.6%) patients received the concurrent percutaneous drainage as well as antibiotics. Hospital mortality was 7.1%. A higher initial serum CRP level (20.3 vs. 49.8 mg/dl, p = 0.02) and HbA1c level (8.7 vs. 16.4, p = 0.01) was associated with hospital mortality.
CONCLUSIONS
Antibiotics alone provide a high success rate for the treatment of EPN. Higher serum CRP and HbA1c level was associated with a higher mortality rate in patients with EPN.

Citations

Citations to this article as recorded by

Analysis of Kidney Computed Tomographic Findings in Patients with Acute Pyelonephritis and Septic Shock
Soonseong Kwon, Sangchan Jin, Wooik Choi, Sungjin Kim
Korean Journal of Critical Care Medicine.2013; 28(4): 272. CrossRef

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