Stones, stents, sepsis, and the need for some common sense

"If we can’t get the emergency rooms physicians to apply a bit of common sense to medicine, maybe we should require that they all have a ureteral stent placed for a few weeks during their residency so that they have a better idea of what these patients go through," writes Henry Rosevear, MD.

The disease kills almost 270,000 Americans a year. It leads to multi-system failure and, even if survived, can leave severe disability. What is it? Sepsis. Hence, I don’t mean to minimize it or make light of the necessity to promptly identify those patients with sepsis. On the contrary, establishing strong evidence-based guidelines on how to identify and treat these patients is key. I do think that, though, that a bit of urological input may be needed when considering these guidelines.

Let’s take 1 of the most common urological consults I receive, the “infected stone.” It’s 2 a.m. and the emergency room doctor calls reporting a 45-year-old man who was tachypneic and tachycardiac at presentation. He has a white blood cell count of 13,400 and his urine is positive for red and white blood cells, but nitrate negative. He also has a 5-mm ureteral stone that is “obstructing” by radiology report. The emergency room doctor informs me that the patient meets systemic inflammatory response syndrome (SIRS) criteria and needs emergent intervention.

Let’s start with the SIRS criteria. A patient has SIRS and should be assumed to have sepsis if they have a temperature higher than 38 degrees Celsius, heart rate higher than 90, respiratory rate higher than 20, and white blood cell count higher than 12,000. Throw in a urinalysis that is positive for leukocytes and now you have SIRS with a suspected urinary source.

Again, sepsis kills and at this point there is nothing wrong with resuscitating the patient, culturing blood and urine, and obtaining imaging studies. So far so good.

But what about that 5-mm proximal ureteral stone with moderate hydronephrosis? Suddenly, I receive a consult for an “infected stone.” A 5-mm stone is a pretty straightforward ureteroscopy and with operating room time so tough to come by, it’s tempting just to book the patient for a 25-minute ureteroscopy and stone removal. But can/should you do that when the emergency room physician has documented that the patient is septic? We all know that, in rare situations, even patients who have perfectly normal urinalysis before ureteroscopy go truly septic after surgery, and can you risk that in this patient? How do you justify it to the family (or the lawyers) if there is a complication? Are you forced to place a stent and treat the stone at a later date? I realize that for a 5-mm proximal stone (especially one that is clearly visible on the scout CT film), most of us would be tempted to stent and then do ESWL as an outpatient, but what if the stone was mid ureter? Or what about a very distal stone?

Or how about this even more common situation. Let’s take the patient who had a stent placed for whatever reason and now presents with the same symptoms? Stents are exceptionally irritating and every patient with a ureteral stent I have known has leukocyte-positive urine, but not every one of them has a raging urinary tract infection (UTI). Do we have to treat every stented patient with leukocytes in their urine for a suspected UTI until we get a culture back?

A little common sense needs to be applied here. The emergency room physician should document that with an obstructing stone present (or a ureteral stent for that matter), the patient’s presenting signs and symptoms can be explained by the normal physiological response to such a stone. The patient may be septic; no one is arguing that, but input from the consulting urologist regarding that decision is vital to prevent unnecessarily turning a 25-minute ureteroscopy into a 2-step procedure (cystoscopy with stent placement followed by outpatient ureteroscopy at another time).

And if we can’t get the emergency rooms physicians to apply a bit of common sense to medicine, maybe we should require that they all have a ureteral stent placed for a few weeks during their residency so that they have a better idea of what these patients go through.

Rosevear is a urologist in community practice in Colorado Springs, Colorado

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