Bedside emergency surgical decompression and venoarterial extra‐corporeal membrane oxygenation for obstructive uropathy with uroseptic cardiomyopathy‐induced arrest: A case report

Abstract

Background: Septic shock combined with septic cardiomyopathy greatly increases the risk of mortality in elderly patients. Patients with a rapid deteriorating state unresponsive to standard resuscitation may benefit from extra‐corporeal membrane oxygenation (ECMO). In cases where obstructive uropathies lead to urosepsis, emergent decompression with double‐J (D‐J) stenting may be necessitated.

Case Presentation: We report the case of a 72‐year‐old woman who arrived at the emergency department and rapidly deteriorated into a state of shock. During the process of resuscitation, emergent biochemical and ultrasound results suggested septicemia and septic cardiomyopathy due to urinary tract infection caused by ureteric stone obstruction. She was transferred to the intensive care unit to be put on venoarterial ECMO after failed resuscitation. Given the suspected diagnosis, it was decided that an emergent bedside digital disposable flexible ureteroscopy (ddFURS) and D‐J catheterization to be performed as rescue decompression procedure. The patient was successfully stabilized with received antibiotic and continuous renal replacement therapy (CRRT) before being transferred to the cardiology department to correct her arrhythmia. She was weaned off CRRT and was able to walk without the need of aids upon discharge.

Conclusion: Uroseptic cardiomyopathy can rapidly progress to renal and cardiac failure. Emergent decompression with ddFURS and D‐J stenting can be performed effectively even in a patient with venoarterial ECMO for rescuing uroseptic cardiomyopathy‐induced arrest secondary to obstructive uropathy. Short‐term outcomes were favorable. However, long‐term prognosis remains to be elucidated.

Graphical abstract

Keywords

case report / extracorporeal membrane oxygenation / septic cardiomyopathy / urosepsis / urological surgery

1 INTRODUCTION

Currently, there is no formal definition for sepsis‐induced cardiomyopathy. Certain literature described the phenomenon as sepsis‐related Takotsubo cardiomyopathy. L'Heureux et al.[1] proposed a diagnostic criteria including the following features: (1) acute and reversible within 7–10 days; (2) global, biventricular dysfunction with reduced contractility; (3) left ventricular dilation; (4) diminished response to fluid resuscitation and catecholamines; (5) absence of acute coronary syndrome as the etiology. Regardless, the etiology is of septic origin[2] and can lead to multi‐organ failure followed by shock[3].

Ureteral obstruction is a common clinical problem that requires immediate treatment to prevent the complications of long‐term obstruction, such as pain, infection, and renal failure. Prompt management should be performed for therapeutic relief. Current options include percutaneous nephrostomy (PCN) and double‐J (D‐J) stenting[4]. Urosepsis accounts for 20%–30% of sepsis cases and the development of shock is associated with high mortality, which is mainly caused by infection‐complicated obstructive uropathy[5]. Extra‐corporeal membrane oxygenation (ECMO) is a remedial measure for patients with refractory septic shock that have failed traditional therapy involving vital organs[6]. Several studies have demonstrated an increasing trend in the use of ECMO and in‐hospital survival rates[7].

We report a case of uroseptic shock and septic cardiomyopathy‐induced arrest in a 72‐year‐old female that was successfully rescued using VA‐ECMO (venoarterial ECMO) and emergent bedside D‐J stenting.

2 CASE PRESENTATION

A 72‐year‐old female was admitted to our emergency department due to dyspnea and recurrent vomiting for 2 days. She was febrile (40.4°C) and had disturbed consciousness. Upon arrival, her vitals were quickly deteriorating to 70/45 mmHg blood pressure, 168 beats/min pulse rate with an irregular rhythm, and 25 breaths/min breathing rate. Past history was significant for hypertension and hyperthyroidism that was well‐controlled for 10 years. Emergent biochemical results returned with raised inflammatory markers, deranged liver function, hypokalemia, and acute renal and cardiac failure.

The emergency team immediately initiated crystalloid infusion and cardiopulmonary resuscitation while transferring her to the intensive care unit (ICU). Intravenous (IV) Meropenem was given and the patient was placed on mechanical ventilatory support with endotracheal intubation. A central venous catheter was established for temporary hemodialysis. Due to ineffective resuscitation and her state of septic shock, the ICU team decided to initiate VA‐ECMO. The venous leading‐out end and arterial leading‐in end catheters were placed in the right and left femoral arteries respectively.

Since the patient relied heavily on mechanical circulatory support, she was not immediately sent for urgent computed tomography (CT) scan. Instead, bedside echocardiogram and abdominal ultrasonography (USG) were performed. Cardiac function detected through the chest wall indicated cardiac wall motion abnormalities and left ventricular ejection fraction 30%. A right proximal ureteric stone measuring 13.0 mm × 8.5 mm was found responsible for obstruction and mild pelvicalyceal dilation (Figure 1).

Based on the final diagnosis of septic cardiomyopathy and uroseptic shock caused by right ureteric stone obstruction, an urgent multidisciplinary team discussion was held. Urologists suggested bedside decompression either by D‐J stenting or PCN, in which interventional radiologists deemed the latter relatively contraindicated as the patient was on anticoagulants during VA‐ECMO.

The ICU facility was temporarily repurposed as an operation field and relevant surgical equipment was transferred. The patient was carefully placed in lithotomy position. Under direct vision, a flexible ureteroscope (REDPINE, Shenzhen, China) was inserted into the bladder and no abnormality was detected along the bladder wall and bilateral ureteral orifices. Under USG guidance, a guidewire was introduced through the right ureter orifice to ascend to the renal pelvis. An Ultra 5 Fr ureteric D‐J stent was inserted along the guidewire, which eventually passed a large volume of abscess (Figure 2). Final USG confirmed the position of the D‐J stent and the operation was concluded. The total operative time was 20 min (Figure 3).

The patient remained in the ICU for 15 days on antibiotics (IV Meropenem Q12H + IV Vancomycin 500 000 Units Q12H), continuous renal replacement therapy (CRRT), IV cortisol 50 mg Q6‐8H, and immunoglobulin therapy. She was successfully weaned from ECMO therapy on Day 6 and ventilatory support on Day 6. On Day 16 of admission, uroculture returned negative and she was transferred to the cardiology department to receive antihypertensive, antiarrhythmic, and lipid‐lowering therapy. Her family refused to undergo a coronary angiogram despite the diagnosis of ventricular fibrillation and septic cardiomyopathy. Bedside echocardiographic patterns were re‐evaluated daily.

She was discharged on Day 29 once the cardiologist declared that her cardiac function was stable. The patient did not require hemodialysis or walking aids. Changes of inflammatory biomarkers, renal function, and cardiac function throughout her hospital stay were summarized in Table 1, which showed effective recovery. At 9‐month follow‐up, the patient declared that she could take care of herself.

3 DISCUSSION

As far as known, this is the first report on VA‐ECMO with emergent bedside D‐J stenting to rescue an elderly patient with uroseptic shock‐complicated septic cardiomyopathy. Under this dire situation, physicians‐in‐charge faced several challenges, including (1) difficulty in making a definitive diagnosis when the patient's vitals were rapidly collapsing. While on VA‐ECMO, physicians‐in‐charge intelligently utilized bedside and portable equipment to identify the possible problem without delaying treatment; (2) bedside D‐J stenting was performed within the ICU, which required rapid transfer of relevant surgical instruments from the operation room.

Septic‐induced myocardial dysfunctional is generally defined as a functional phenomenon and not biochemical‐wise[8]. Therefore, it is uncertain whether monitoring of biochemicals alone can reflect the severity of the underlying disease process, which renders treatment challenging. Patients with septic cardiomyopathy were significantly associated with a higher risk of 1‐month mortality than those without, especially those with right ventricular dysfunction[9]. Although difficult to detect, physicians should consider its diagnosis in all septic patients with sepsis‐associated organ dysfunction and perform echocardiography, which is the gold standard[10]. The male gender, younger age, high lactate levels upon admission, and a history of heart failure were commonly reported risk factors[1].

It is known that ECMO is a feasible treatment measure to improve the survival rate in pediatric patients with impaired cardiopulmonary function caused by sepsis[11]. The temporary circulatory support allowed a window of opportunity for diagnosis and management for our patient. However, the application of ECMO in adult patients remains controversial as results in treating sepsis are often contradictory[12]. Danial et al. found that hospital and 5‐year survival rates were 44.4% and 42.4% for sepsis‐induced cardiogenic shock[13]. The retrospective study further concluded that although the outcome of VA‐ECMO patients differs depending on etiology, the difference was more related to the severity of the situation associated with the cause rather than the cause of the shock.

Anticoagulation is required during ECMO to prevent thrombotic complications[14,15]. Although PCN can be performed under local anesthesia using ultrasonographic guidance, its most common local complication is bleeding[16,17]. The rate of hemorrhage requiring transfusion following PCN was reported to be 2%–4%[18]. Given these reasons, D‐J stenting was the treatment of choice to minimize the risk of bleeding. In a meta‐analysis, it was found that D‐J stenting was superior in terms of offering a shorter fluoroscopy time, in‐hospital stay, and lesser difficulty in self‐care compared to PCN[19].

Regardless it was difficult to perform D‐J stenting on a patient with ECMO, the bedside area of the ICU had to be converted to a temporary operating room and the relevant equipment had to be repurposed or moved to accommodate the operation. These were completed within half an hour after ECMO. Yang et al. conducted a pilot study on eight patients and found that live renal USG can facilitate a high success rate for bedside ureteral stent placement[20]. In this patient, the guidewire was inserted under USG guidance before introducing the catheter and ureteroscope. A disposable flexible ureteroscope (DFU) was used for the following reasons: (1) less equipment had to be transferred to the ICU within a short period of time, mainly the visualization device; (2) bedside D‐J stenting would require better maneuverability due to the limited space. Previous studies have demonstrated comparable‐to‐superior visibility, maneuverability, irrigation rate, and safety for DFU[21,22]; (3) the patient had not been ruled out of infectious diseases and previous studies had demonstrated up to 100% contamination rate for reusable flexible ureteroscopes due to insufficient sterilization[23]. After successful D‐J stenting, the patient continued her antibiotic and CRRT therapy.

The purpose of CRRT in a septic patient is to effectively reduce the concentration of cytokines in the body to ensure the balance in the body's pro‐/anti‐inflammatory system[24]. This mechanism protects tissue cell damage by inflammatory factors, inhibiting the death of vascular endothelial cells, improving hemodynamic function and tissue perfusion[25]. Zhu et al. described the successful combination of ECMO and CRRT in curing a patient with urosepsis[26]. The 67‐year‐old female underwent holmium laser lithotripsy combined with D‐J stenting that complicated to refractory septic shock. Our treatment was similar except with the addition of D‐J stenting for therapeutic relief.

The main limitation of this study was that the procedure and effective management depended heavily on the cooperation between urologists and ECMO teams. The protocol was performed in a tertiary center that was familiar with the protocol and the decision, and insertion of D‐J stent was performed by an experienced surgeon. This study was only able to describe the immediate effect and early survival of the patient. Further long‐term follow‐up is required to guarantee the feasibility and survival of the patient. Larger retrospective cohorts are necessary to elucidate the effect of this treatment.

4 CONCLUSION

Uroseptic cardiomyopathy can rapidly develop to renal failure and cardiac arrest. VA‐ECMO can temporarily stabilize the patient if standard resuscitation fails. Bedside rescue D‐J stenting may be necessitated for decompression of the obstructive uropathy, followed by CRRT and antibiotic therapy. Short‐term outcomes were favorable. However, a long‐term prognosis is yet to be evaluated.

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2024 The Author(s). UroPrecision published by John Wiley & Sons Australia, Ltd on behalf of Higher Education Press.