|Year : 2008 | Volume
| Issue : 6 | Page : 840
Anaesthetic Management of Nephrectomy for Emphysematous Pyelonephritis
N Dua1, AB Upadhyay2, PK Pradhan3, Jayashree Sood4
1 Consultant, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi - 110 060, India
2 DNB Resident, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi - 110 060, India
3 DNB Urology Resident, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi - 110 060, India
4 Senior Consultant & Chairperson, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi - 110 060, India
|Date of Acceptance||27-Aug-2008|
|Date of Web Publication||19-Mar-2010|
Department of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, Sir Ganga Ram Hospital Marg, New Delhi - 110 060
Source of Support: None, Conflict of Interest: None
Emphysematous pyelonephritis (EPN) is a serious and often life threatening infection of the renal and perirenal tissues. The characteristic feature of this infection is the presence of gas within the kidney and perinephric tissues. The triad of symptoms of fever, flank pain and pyuria, especially in a diabetic female patient which did not respond promptly to conventional antibiotic therapy raised the possibility of EPN. CT scan established the diagnosis and the line of management. After failing medical management, uncontrolled frustrating hyperglycemia with fear of septicemia, nephrectomy was done in life threatening fulminant infection of the kidney.
Keywords: Nephrectomy, Renal infection
|How to cite this article:|
Dua N, Upadhyay A B, Pradhan P K, Sood J. Anaesthetic Management of Nephrectomy for Emphysematous Pyelonephritis. Indian J Anaesth 2008;52:840
|How to cite this URL:|
Dua N, Upadhyay A B, Pradhan P K, Sood J. Anaesthetic Management of Nephrectomy for Emphysematous Pyelonephritis. Indian J Anaesth [serial online] 2008 [cited 2020 Jan 29];52:840. Available from: http://www.ijaweb.org/text.asp?2008/52/6/840/60698
| Introduction|| |
Pneumaturia, a sign possibly due to gas forming bacterial infection of the kidney, was reported more than a century ago.  However, the term emphysematous pyelonephritis (EPN) was first used by Schultz et al in 1962 to describe the presence of renal parenchymal gas formation.  EPN is an acute necrotizing infection of the renal parenchyma and perirenal tissue, which results in the presence of gas within the renal parenchyma, collecting system or perinephric tissue. Infections, which cause EPN are severe and life threatening. 70 to 90 % of reported cases are in patients with diabetes mellitus. , It is more common in female patients with left kidney involvement. Obstruction to the affected reno-ureteral unit is present in about 25-30% of the patients.
| Case report|| |
A 48-year-old female patient was admitted with complaints of fever with chills and rigors and abdominal pain of seven days duration. She was known diabetic and hypertensive for many years taking oral hypoglycemic and antihypertensive drugs. The patient was alcoholic and cigarette smoker for last 25 years. Smoker's cough and dysponea on exertion grade II was present. There was no history of urinary obstruction and hematuria. She was conscious and alert. The temperature was 38.5°C, pulse rate 110 per minute, blood pressure was 160/90 mm Hg and the respiratory rate 22 per minute. Cardiovascular examination was within normal limits. On chest auscultation, bilateral fine basal crepitations were present. Abdominal examination revealed a palpable mass with severe tenderness at the left upper abdomen and the left renal angle. The remainder of the physical examination was normal. On chest X ray, left lung basal opacity was present. On echocardiography examination, ejection fraction was 60% and stress echo was negative for ischaemia. A plain x-ray of the abdomen revealed kidney shaped gas in the left renal area [Figure 1]. Computerized tomography of the abdomen confirmed the presence of gas in the renal and perirenal area with extensive renal parenchymal destruction [Figure 2]. The diagnosis of type III A EPN was established. 
Laboratory investigations showed a haemoglobin of 8 gm/dL, total leukocyte count of 18,000/mm 3 and platelet count 82,000/mm 3 . The liver and kidney profile were within normal limits along with normal coagulation profile. The fasting blood sugar was 429 mg/dl and she was put on tight control regimen of insulin therapy. Urine microscopic examination revealed numerous pus cells, 2+ positive for acetone and 4+ positive for sugar. Preoperative ABG was pH 7.28, PaCO 2 46 mmHg, PaO 2 108 mmHg, HCO 3 16 meq/l, BE - 8.5 meq/l, Na+/K+ 142/3.8 meq/l, blood sugar 240 mg/ dl. ABG abnormalities were corrected accordingly. As patient had already received 2-3 days intravenous antibiotics at other centre. So, by assessing the patient's general condition and poorly controlled diabetic status, decision to do an emergency nephrectomy was taken fearing for impending septicaemia.
Patient was nebulizd preoperatively 4 hourly with salbutamol. After optimizing the preoperative status and arranging adequate blood, informed high-risk consent was taken. Anaesthesia was induced with propofol 100mg, midazolam 1mg and fentanyl 100mcg. Neuromuscular relaxation was achieved with atracurium 50mg for tracheal intubation. Anaesthesia was maintained with 33% O 2 + 66% N 2 O with inspired concentration of 13% isoflurane. Intraoperative monitoring included HR, ECG, SpO 2 , CO 2 , arterial blood pressure, temperature, input output and arterial blood gases with blood sugar monitoring at hourly intervals and managed accordingly. Intraoperatively, insulin infusion according to tight control regimen was continued throughout the procedure along with 5% dextrose water intravenously. Perioperative ABG was pH 7.40, PaCO 2 38.4 mmHg, PaO 2 159.2 mmHg, HCO 3 23.7 meq/l, Na+/K+ 143.8/ 3.05 meq/l, BE 2 meq/l, Blood sugar 212 mg/dl and just before reversal, ABG was pH 7.325, PaCO 2 47.2 mmHg, PaO 2 150 mmHg, HCO 3 24.5 meq/l, BE 1 meq/ l, Na+/K+ 145.2/3.13 meq/l, blood sugar 184 mg/dl. About 500 ml of necrotic material was drained during surgery and the blood loss was approximately 250 ml. Total perioperative fluid given were 2L normal saline, 0.5L colloid (hydroxyethyl starch 6%) and total urine output was 300ml. After the completion of nephrectomy, muscular relaxation was reversed with neostigmine and glycopyrrolate. Postoperative ABG was pH 7.36, PaCO 2 37.6 mmHg, PaO 2 146 mmHg, HCO 3 23.6 meq/l, BE 1.2 meq/l, Na+/K+ 143.2/3.53 meq/l, blood sugar 170 mg/dl. Postoperative monitoring was done hourly for blood sugar, temperature, ABG, input output for six hours. Postoperative outcome was uneventful and she was discharged on 6th day of postoperative period.
| Discussion|| |
Emphysematous pyelonephritis(EPN) has been generally regarded as a rare renal infection. 90% of the reported cases have occurred in diabetic patients. EPN has also been reported in debilitated (alcoholic) and immunocompromised patients.  The most common bacteria causing EPN is Escheria Coli, which accounts for 60% of the cases. The exact mechanism of gas formation in EPN is not known. Gas formation is believed to be due to pathogenic bacteria capable of mixed acid fermentation acting in a hyperglycemic environment on tissues that are ischaemic. This results in tissue destruction, and encourages purulent infection and inhibition of the removal of locally produced gas.  The diagnosis of EPN is classically made by demonstrating gas in the renal or peri-renal tissue by plain abdominal X-ray in 33% patients only.  CT scan confirmed the diagnosis and showed the extent of the disease.
EPN can be classified into four types as per the CT Scan findings.  According to the radiological findings on computed tomographic scan, they are classified into the following classes: (1) class 1: gas in the collecting system only; (2) class 2: gas in the renal parenchyma without extension to extrarenal space; (3) class 3A: extension of gas or abscess to perinephric space; class 3B: extension of gas or abscess to pararenal space; and (4) class 4: bilateral EPN or solitary kidney with EPN.
Patients initially seen with risk factors *(i.e. thrombocytopenia, acute renal function impairment, disturbance of consciousness and shock) were associated with very high mortality.  The flowchart for management of EPN according to the clinicoradiological classification is shown in Flow chart 1.  [Additional file 1]
For localized EPN (class 1 or 2), percutaneous drainage (PCD) and/or relief of the urinary tract obstruction (if it exists) combined with antibiotic treatment can provide a good outcome. For extensive EPN (class 3 or 4) with a more benign manifestation (i.e. < 2 risk factors), PCD combined with antibiotic treatment may be attempted for preservation of renal function as much as possible. However, nephrectomy can provide the best management outcome and should be promptly attempted for extensive EPN with a fulminant course (i.e.> 2 risk factors) or for cases with an unsuccessful conservative management.
Mortality for surgically treated patients is 20% compared to 80% for patients treated medically. , After failing conservative line of management, rapidly deteriorating general condition of the patient and the fear of septicaemia prompted us to go ahead with nephrectomy.
To conclude, EPN is a severe and often life threatening infection. CT Scan is the investigation of choice for not only making a proper diagnosis but also in planning the treatment option. Renal preservation must be the aim of treatment, but this must not be at the cost of patient's life. One should not hesitate to resort to nephrectomy as and when indicated. Anaesthetic consideration must aim for tight control of blood sugar pre, peri& postoperatively. Appropriate management of acid-base and electrolyte imbalance should be done vigorously for the successful outcome.
| References|| |
|1.||Kelly HA, MacCallum WG. Pneumaturia. JAMA 1998; 31:375-381. |
|2.||Schultz EH, Klorfein EH. Emphysematous pyelonephritis. J Urol 1962; 87: 762-766. |
|3.||Evanoff GV, Thompson CS, Foley R, Weinman EJ. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med 1987; 83:149-154. [PUBMED] [FULLTEXT] |
|4.||Patterson JE, Andriole VT. Bacterial urinary tract infections in diabetes. Infect Dis Clin North Am 1995;9: 2551. [PUBMED] |
|5.||Heinemann S. Emphysematous pyelonephritis. J Urol 1984; 131:203-208. |
|6.||Huang JJ, Chen KW, Ruaan MK. Mixed acid fermentation of glucose as a mechanism of emphysemtous urinary tract infection. J Urol 1991; 146: 148-151. [PUBMED] |
|7.||Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000;160:797-805. [PUBMED] [FULLTEXT] |
|8.||Wan YL, Lo SK, Bullard MJ, Chang PL, Lee TY. Predictors of outcome in emphysematous pyelonephritis. J Urol 1998; 159:369-373. [PUBMED] [FULLTEXT] |
|9.||Shokeir AA, El-Azab M, Moshen T, El-Diasty T. Emphysematous pyelonephritis: A 15 year experience with 20 cases. Urology 1997; 49:343-346. |
|10.||Shahatto N, Al-Awadhi NZ, Ghazali S. Emphysematous pyelonephritis: surgical implications. Br J Urol 1990; 66:572-574. |
[Figure 1], [Figure 2]