Hey everyone, I'm Brandon Odo.
And I'm Brian Bowling.
And this is Critical Care Scenarios, the podcast where we use clinical cases, narrative storytelling
and expert guests to impact how critical care is practiced in the real world.
Hey everybody, welcome back to the podcast.
I'm Brian Bowling and with me is always is my cohort Brandon Odo.
We have a special guest with us today to class up the show a little bit.
Dr. Ashley Winter, she is a board certified urologist who did her residency at NYU Presbyterian
or New York Presbyterian Cornell.
Yeah, it's separate, it's separate.
It's actually Cornell and Columbia are part of the same hospital system.
It's weird, I don't know.
But NYU is separate.
So New York Presbyterian Cornell, not NYU, the place stinks.
But then went to Portland, Oregon, kind of hopping across the country and was practicing
there for five years before now.
She is the chief medical officer of Odella Health.
And we're going to talk a little bit today about some urology stuff in the ICU.
I think Brandon's got a case for us.
Yeah, we do.
I thought we would get into some relatively fundamental stuff.
But something we see pretty often, and we understand, I think, our ICU side of it.
But a lot of the time we have blind spots about how the surgeons think about these problems.
So Ashley, you are covering the inpatient urology service at your local unnamed hospital.
And they call you about a patient who rolled into the ED.
It's a 61-year-old female.
She has a history of some diabetes, hypertension.
She does have a history of her current UTIs.
And she describes having about a week or so of some pain when she urinated and some
urinary frequency.
You know, she's had UTIs in the past.
She says that was kind of how it felt.
And then, since about yesterday, she started to have some pain in her flank and in her
lower abdomen, kind of shooting down into her groin.
And then today, she really is just not feeling well.
She's feeling very weak, a lot of malaise and just generally ill.
She thought she might have a fever.
So she came into the ED.
At triage there, they take her vitals and she's hypotensive down to 80 over 40, which is
a map of around 55.
She's tachycardic around 110, 115, and she is febrile at 38.1.
She just is very kind of restless and uncomfortable looking.
They do a UA, which shows 3 plus blood, 1 plus leukocytes, 1 plus bacteria.
And they run her through a non-contrast CT scan of her abdomen in pelvis.
And that shows an obstructing stone in her proximal left ureter, it's about a centimeter,
and hydrinifrosis of that left kidney.
The bladder is somewhat distended too.
So the emergency medicine folks were thinking, well, I mean, this looks like maybe a UTI
and clearly there's obstruction.
They start around some broad antibiotics.
It's a pepper sill and taser-backed him and a vanke of mice and for her.
They give her some fluids and her blood pressure actually responds.
They give her a liter or two and her map is around 70 now.
And they call U for urology to get your take.
So just give me an initial sense for this type of problem.
What are the kind of key pieces of information and decision points that you're thinking about
just initially when you hear about a patient like this?
You know, I mean, that is a perfect recipe for needing to unobstruct them, meaning, you
know, either a stent or a percutaneous infrostomy tube.
So to the extent that this is a septic patient, I mean, we sort of know how to treat that.
But is a good way to think about this problem kind of analogous to someone with like an
abscess that needs to be drained?
You have the source of infection is not just like a cellulitis, something in your tissue,
but it is failing to drain itself because something is blocking it.
Yeah, 100%.
I mean, with this sort of person, you know, in terms of giving them a good clinical
outcome, decompression of their urinary system is absolutely essential and doing it sooner
than later is absolutely essential.
You know, these are the patients that can go from bad to dead if you don't decompress
them right away.
And the reason, of course, as you are alluding to is because when the stone is obstructing,
you know, you develop that high intra-reno pressure and that can allow, you know, it's a source
whereby bacteria, you know, are kind of continuing to seed into the bloodstream because the
urine kind of can't drain.
So, you know, one thing I would comment from the, you know, stone assessment side of this
is when they say, you know, an obstructing stone in the, in the ureter, right?
Now this person, if they come in with the same clinical picture, and they have a one centimeter
stone in the ureter, whether or not they have hydronephrosis, if they're presenting with
data that suggests a UTI with hemodynamic instability and a stone in their ureter,
whether or not they have hydronephrosis, that person, we should attempt some sort of drainage
of their kidney.
And I say that is because somebody could come in and be profoundly dehydrated because they
are so ill and, you know, maybe the hydronephrosis is mild, we're not even present, but we really
know that a stone that size in the ureter is going to be causing an obstruction.
And this is one of the reasons why when somebody comes in critically ill and you have a suspicion
for a kidney stone, you know, I highly recommend doing a non-contrast CT scan as opposed to,
you know, people who do an ultrasound, because sometimes an ultrasound can miss something
like this, right?
Because the renal ultrasound does not completely image the ureter.
And so that will tell you the presence or absence of hydronephrosis, but it really won't
give you a complete picture of the ureteral anatomy.
And certainly I have had people with just mild hydronephrosis, you know, ureteral stone,
in the same clinical picture, and, you know, we placed a stent and a whole bunch of pus
came out, and they had a clinical improvement where you're talking about having them referred
either for nephrostomy or stent, they're going to need a stent most likely because, you
know, interventional radiology has trouble if the degree of hydronephrosis is less, you
know, placing, placing an access point into the renal pelvis.
Okay, so in a sick patient, or let's say a sort of septic looking patient who has a stone,
well, I guess let's say anywhere in a ureter, you would kind of consider them to be obstructing
until you prove otherwise.
I guess we should say someone who seems to have a UTI, or is that sometimes difficult
to say as well?
I mean, my statement here would be if somebody's septic and they have a stone in their ureter,
you should try to place this thing.
Okay, and that's because to prove that it's obstructing is sometimes tricky because hydronephrosis
is not always obvious, although if it's present, that certainly supports the case.
The overall point is that the radiographic definition of obstruction in the ureinary tract,
I believe, is related to hydronephrosis and not the anatomic position of the stone, but
from a urology standpoint, the size and the location of the stone are the most important
thing.
So that would be kind of the way of distilling what I'm getting at.
You know, I get called sometimes by providers, you say, oh, this stone is severely obstructing,
right?
And I look at the scan and it's a one millimeter stone and it's right by the ureter
vesicle junction, right?
That means where it's about to come out and there is severe hydronephrosis.
But that person is about to pass that stone, right?
That person is 99.9 percent going to pass that stone, so they don't really need a urologic
intervention, even if the degree of hydronephrosis is profound.
And even if the radiologist reads it as a severely obstructing, right?
Because we're looking at it from the standpoint of the size and the location.
Now, if that person has a one millimeter stone right by the ureter vesicle junction about
to pass into the bladder and their septic, that's a more complicated story.
And you know, that's certainly the person where you consider putting a stent regardless
because you don't want their infection to get worse.
And for, obviously, for them to not have an issue with their, to not be able to have
source control.
And we're talking about stones in the ureter, a stone that's just in the kidney is not
going to be causing obstruction.
Well, this is also a very 90 percent of the time you are correct.
You know, there are some instances where you have abnormal, renal, intravenial anatomy.
So there can be something like a calisill diverticulum that is where one of the renal
calisies, let's say, has a diverticulum, right?
And you could have a stone sitting in that blocking that part of the kidney from draining,
right?
And so you could have a part of the kidney that has hydronephrosis without the like a
segmental hydronephrosis, right?
These things are uncommon and a sophisticated, you know, you kind of need a sophisticated
lens to look at them.
I have seen people on occasion that have a component of their intravenial anatomy that's
that's obstructed when the rest isn't and they don't have a stone in the ureter.
Of course, this is why, you know, as a urologist, you need to look at all the scans yourself.
You know, I, when I get called about these patients, I, you know, if there's a stone,
if somebody has a UTI and they're septic and the ER or the critical care provider wants
to just call me and say, hey, can you look at this scan?
I'm happy to do that, right?
And I can say, yeah, that stone is not obstructing.
You don't need me, right?
That's fine.
But, you know, so, so I'd say if somebody has a specific concern, you know, you can call
us and ask us to look at the scan, 90% of the time, you know, you're not going to need
a, need a stent.
I'm kind of like going off the zebras, but, you know, from the, like, ultra-sophisticated
lens of, of urologic considerations.
In the, like, canonical case of the stone in the ureter septic patient, is there any
circumstance that patient would not need to be decompressed?
We kind of said one possible one where it was really little and it was almost all the
way through.
Maybe you could say, well, it's about to pop out.
Is there any other situation or it's pretty much, there's no way around this unless it's
like the patient is going to be, like, a comfort measure or something, you know, but almost
never, I mean, this is what I will say.
There is the patient who comes in with a obstructing ureteral stone and their septic, right?
And their septic is from something else because they don't have a urinary tract infection,
right?
So, and that, that definitely happens, right?
So that person, maybe they actually also have whatever pneumonia or divertitulitis or
what, what have you, right?
And, and their stone is an incidental finding, right?
And in that case, you do have to be careful because you don't want to take somebody who
is, you know, unstable, hemodynamically unstable and subject them to anesthesia for something
that isn't going to lead to source control, right?
And I'd say a classic case of this is somebody right there coming in, maybe they have flank
pain, they don't have urinary symptoms, but they're hypotensive, you know, febrile, the
ER gets the CT scan, you have the stone in the urinary tract, and you have a UA that looks
dirty, right?
And that's when, but they didn't have uti symptoms, right?
So that's when I ask the ER to get a straight path urine sample, because there are patients
who give a clean catch and they have an improper technique, right?
Or because they're coming in, you know, hypotensive and unwell, maybe they're dehydrated, or maybe
they can't really give a good sample, and it is so important, this is another thing
if like there's one takeaway from the people who listen to your, to your podcast is to get,
you know, a urine sample, and a good urine sample right away, and before, you know, antibiotics
are administered, administered because that can, that can lead to, you know, diagnostic
conundrum.
And of course, obviously, if there's no other possible source, you know, then to definitely,
definitely consider it, right?
Like if they don't have any sign of pneumonia, or they don't have a, refer to a diverticulus,
diverticulitis, right, then, then fine.
And this is also where it gets more complicated.
If they have a real complete obstruction, there is a possibility that they have pylon
arthritis behind the stone, and they have a clean urine analysis because they have no
infection in the bladder, and they only have an infection in the kidney behind the stone.
That's not very common, but it does happen.
So if they have a, if they are having a critical picture, they do have an obstructing
your renal stone, and they have no other potential source for their sepsis, then you probably
need to assume that they have an infection behind the stone that's not being reflected
on their urine analysis, and that they probably need urgent decompression.
It sounds like I'm complicating every situation more than simplifying it.
Well, medicine is complicated.
Yeah.
Well, so we kind of understand these patients by and large need to be decompressed, then we'll
get into the techniques, but what's your general timeline for this?
You said it needs to be done fairly promptly, but are we talking about within a couple
hours, same day, within a few days, how urgent is this?
Yeah, I would say within a couple of hours, I mean, as soon as possible, right?
So this patient comes in at midnight.
Is this an overnight kind of thing or a first thing in the morning kind of thing?
Over night.
Over night.
Absolutely.
100%.
Over night.
This is the patient.
Now, let's say they come in and they have mild UTI symptoms, and they have a stone,
but they're 100% hemodynamically stable and perfectly well, then that person's not
going to leave the hospital before I decompress them.
But maybe we're waiting, you know, for first thing in the morning, right?
The person who's unstable and hasn't obstructing stone, the UTI, that person you have to do
as soon as possible.
What would you do in the office with somebody who was not septic, but had a UTI, and maybe
you got a scan, and they had a stone?
Yeah, that's a great question.
I love this question.
So in my last practice, we had access to fluoroscopy in the office.
So if the patient was willing, sometimes I would place a stand in the office, you know,
you have to understand that that is highly dependent on an individual patient's tolerance
for an invasive procedure in the clinic, right?
Because you are putting a number of instruments through their urethra.
So I have done that in both men and women, but again, you know, it needs a high degree
of patient tolerance or interest, right?
But there are people who are like, I just want to deal with this right away.
That said, otherwise, if they are in my clinic, we see that they have evidence of a UTI
or an analysis.
We have a scan that shows an obstructing stone, you know, what I'm going to do is if they're,
you know, if there's concern that I have that they may become unstable, right?
Like they're very elderly, high comorbidities, etc., then I'm going to tell them first
to be NPO, that is the most important thing, and go to the emergency room or we'll arrange
for them to have a transport to the emergency room.
You know, if they have a UTI, maybe they're healthy, younger, they have evidence of a stone,
but again, all their hemodynamic signs are stable, then, you know, that might be the
person where I'm calling my colleagues and assessing, you know, if I can get them
edit on directly to the OR without going through the emergency room.
All right, so we talked about decompression usually falls into two categories.
Just give us a kind of brief summary of these two approaches, what they look like in a
general sense and how and when you would consider one versus the other.
Sure. So the two options are a readeral stent, you know, to kind of do an overview of what
that is, that's basically where a urologist goes in through the urethra and deploys
this, this plastic tube that has a curl, one curl is deployed to be within the renal pelvis,
the other curl goes within the bladder, and that allows urine to drain around the stent,
right? So it's not like a cardiac stent that is deployed to expand the lumen, right?
It's a piece of plastic with a non-expanding lumen and the urine flows, flows around it.
It's also intended to be temporary. They can only stay in for a maximum of about three months,
but so, you know, either they're going to have to come back after their infection is treated,
their sepsis has passed to have that stent removed after serial imaging that demonstrates
that the stone has passed, or they're going to have to come back to the urology and have a
surgical procedure to remove their stone. So that's the, you know, basics with a stent,
important things to know is that we generally use that at a minimum IV sedation in the operating
room with that, just because, again, you're putting generally a rigid metal sister scope through
the urethra to deploy that stent, right? So imagine having a large rigid metal cystic scope
going through your urethra. You don't usually like having that while you're not anesthetized.
So, you know, that is a consideration that goes into it is the extent and degree of anesthesia
that's required for that. So that's, that's number one. And there are certain times when like,
you really, really can't utilize a stent first line. Typically, that's going to be more of
somebody coming in with a, with a hydronephrosis or an obstruction related to, let's say, a large
pelvic mass, right? Or something where we feel like the anatomy is so distorted that it's going
to be hard for us to find the urethral orifice, right? It's going to be hard for us to access
the upper urinary tract from the bladder, okay? Usually with a stone, it's not an issue, but
you know, there are times when right off the bat where like, we're not even going to try a stent
in this person and usually it has to do with really severe distortion of the pelvic anatomy.
The other option is a percutaneous nephrostomy tube. Most hospitals that's done by
interventional radiology, and that's basically where the radiologist, you know, typically has the
patient prone, right? So laying face down and they're using, imaging, typically ultrasound
to visualize the renal pelvis and they access that with a, you know, with a needle and they deploy
a small, what we call like a pigtail catheter that curls within the renal pelvis and directly exits
the body, right? So the upsides with that is it typically requires less anesthesia, right? Sometimes
they can just use local even, right? Because they're not going through the rethra, so it's less,
there's less of a tract that can be painful when they're placing that nephrostomy tube.
You know, obviously if the patient can't be prone for some specific reason that can make it
very difficult. Other things that can make it difficult, as I mentioned earlier, if they don't
have severe hydromyphrosis, maybe they're dehydrated, that can make it more difficult, you know,
people with a much larger body habitus, it can be quite difficult and those people might prefer
eventually need a stent. And then, you know, from the patient's standpoint, you end up with a urine
bag, right? So unlike a stent, which is all internal, the pyrcutaneous nephrostomy tube, and I'm sure
people who listen to this are aware of that. But, you know, when you have the pyrcutaneous nephrostomy
tube, you have a urine bag sitting around. Now, if it's there to save your life, that's fine,
but it's frustrating for a lot of people while you have it. That said, of course, it's never,
it's not intended to be permanent. And once their infection is treated and their stonus
manage, you know, typically that tube is going to be removed. The other important thing from a
critical care standpoint is if, you know, the patient is on anti-coagulation or a specific
anti-platelet agent, interventional radiology would likely not want to place a nephrostomy tube,
because, you know, you are putting a needle directly through the renal perankoma, right? And
that's highly vascularized tissue. And so you don't want to end up with a, you know, perinopherchymatoma,
for example. So, so that's another consideration that comes into it. The probably one of the
largest factors, of course, is institutional, right? Where I was practicing general urology
as an attending for over five years, you know, the expectation was that in all cases, unless urology
felt it was absolutely impossible to place a stent, or they had already tried and failed
interventional radiology just basically wasn't going to do it. So, you know, the expectation was
that we tried first, or we felt like it was impossible, and then they would do it. So, you know,
I'd say to your collars, I mean, to your, I would say to your listeners, you know, you're probably
already aware about your institutional policies, or typically you're just consulting your
biology because of patients critically ill, and they have an obstruction, and your first-line
consult for that patient is just not interventional radiology anyway, and then we make that recommendation.
So, you're probably going to be contacting us no matter what is my assumption.
So, in some number of patients, there are technical considerations for one versus the other, and then,
you know, it's a little bit more of a burden to have than a frost in me, because you have an
external device in place, but the rest of the time it may just be a matter of who's more available,
or willing, urology versus IR. Yes. Okay. And then both these devices are going to stay essentially
until patient stable, the infection has cleared, and the stone has passed. Or they come see us, and we,
you know, urology arranges an outpatient procedure to manage the stone. Yes. Okay, it's passed
spontaneously, or with your help in other words. Yes, yes, exactly. And if they have a massive stone,
like something like a staccorn calculus, it actually might be advantageous to have the
pericutaneous nephrostomy, because the type of surgery that you do on those stones is one called
the pericutaneous nephrology, and that's where you actually go directly through that hole in the back
to get rid of the stone. For smaller stones or stones in the yurt, we do a surgery called
to reteroscopy, where we put a camera directly into the yurt, and blast up the stone. But that
would be another indication. So if somebody comes in and they're septic, and they have a massive
stone in their kidney and an infection, we might recommend that they have a pericutaneous nephrostomy
to place, because that is advantageous for their ultimate stone management, and it will achieve
the appropriate immediate clinical outcome of decompression. And there is really no situation
ordinarily where either in the nephrostomy or the stent is going to be left in place long term
for this sort of indication. I know we've all seen people with long term nephrostomies and such,
but it's not really for stones. Not really for stones, no. Again, with the exception of somebody
or saying is, you know, kind of end of life maybe, and you know, the family wanted their immediate
success managed, but no other procedures, let's say, but for the stone patient, they're not going
to have that long term. Patient like this when we're in this initial phase of managing them.
Do you care if somebody puts a folly in them? Is that good bad, doesn't matter?
Critically, if they're critically ill, and we do a decompression, we typically leave a
catheter in them, you know, at least in the initial 24-hour period, like if I'm placing a stent
and you're septic, I put a folly in the operating room at the end of the case.
And if we already have one in, you'll just take it out to do the scope and then potentially
replace it. Oh, yeah. Yeah, you have to. And this is, yeah, you have to, because our access point
to do this whole procedure is through the urethra. Are there any stones that because of their size
or maybe their location, you cannot stent, you cannot get a stent around them?
Yes, that is also a very excellent and sophisticated question. So there are what we call impacted
stones. Sometimes we can't get a stent around them. I'd say it's not super common, and usually
there are some some tricks to navigate those. Like we have special types of wires that are hydrophilic,
that are very slippery, that help you get around those stones. But there are times
when I have attempted to place a stent, and it's just 100% impossible. Let's say maybe this person
has had the stent for quite some time, and it's very impacted. And that's the sort of situation
where I'm probably have tried the stent, and I call, you know, the interventional radiologist,
and I'm like, hey, I just cannot get this in. Can you do enough for us to me?
I think a lot of us who take care of these patients kind of after their procedure have found that
they often seem to get worse after the decompressed. This is common phenomenon where they seem to,
even if they're kind of quasi-stable before, like this patient, sometimes they just become very
floridly septic looking after, and much more hypotensive and so on. Have you found that to be the case?
Yes. And there are some reasons, right? So there can be a component of
Iatrogenesis here, because when I am placing a stent, right, what I first do is I,
right, once I get into the bladder, I identify the neuronal orifice, I pass the wire up to the
kidney, and then I pass a small open-ended catheter into the kidney, right? And what I try to do
is allow the kidney to decompress a bit while I'm standing there with this open-ended catheter,
right? It's like a very long, very skinny tube. It's actually five French, so if you know,
you know, are familiar with French, it's five French, and it's several feet long. So,
but if it has a rapid drip, then I allow that to decompress. But then before you put the stent,
typically what you're doing is injecting some contrast medium into their renal pelvis,
so that on the fluoroscopy in the operating room, you can make sure that your stent,
your proximal stent curl is in the correct space, right? And so if you are not very careful and you
inject too much contrast, or you don't allow this, the renal pelvis to decompress before you inject
that contrast, then you are basically hitting that renal pelvis with a high degree of pressure,
right? You know, I don't know if there's any studies looking at like
the specific quantity of contrast, medium injected, and sub-transient clinical worsening after
this procedure, but it is at least from a urology standpoint, you know, a kind of common
lore that you have to be really careful with the amount of contrast that you inject directly
into the renal pelvis, because you don't want to, you know, just pressure slam
that bacteria into the bloodstream. So there's that. Yeah, I mean, and this one component of it,
and then, you know, I'm sure it's just, you know, instrumentation in general leads to some
some clinical worsening, and then I think also it's just a lag, right? I mean, these patients
come in at the precipice of becoming the precipice sometimes of death, really, and we caught them,
and their clinical picture is just, you know, proceeding as it would of, and they need some time
to have the benefit of the decompression. So there's a few ways of looking at that, right? Like,
a component of isogenesis, a component of the natural progression of how ill they were, and they
have a delayed improvement. Any opinion on antibiotics, either selection or the duration, or can we
just treat these like any complicated UTI empirically and then narrowing if we get some cultures?
If somebody has a complex urologic history and has presented with stones in the past,
you know, and I'm sure you do this as critical care providers anyway, you're going to want to
look through their history and see how they have cultures done in the past, right? And some of
these patients have a history of a multi-drug resistant organism, or, you know, they've even had
stone culture done, which we like to do sometimes in urology, because sometimes there's a
there's a latent bacteria that's actually embedded within the stone that's not typically found
on their own culture. So in any of these patients, I think it isn't important to look through their
history, and of course, you know, if you have an EMR that doesn't allow access to outpatient
records, then at least, you know, the next morning, trying to contact the office of their urologist
to get some of that data is very important, and we always appreciate when that data is on hand.
Are there any other important complications of either of these procedures that people should be
aware of? We talked about maybe bleeding after a percutaneous drainage, anything else that can
happen even infrequently. You know, for example, there can be stent migration. So, you know, at times,
if the patient is continuing to get worse after you do the stent, right, like not just the typical
window of, let's say, a number of hours, but it's two days afterwards, right, and they're still
doing worse. You know, it could just be because they're critically ill, and they've had, you know,
kind of end organ damage, you know, from their initial insult, but we always at least do some
repeat imaging if that case is happening. So, the easiest thing you can do, especially in the ICU,
is start with a bedside KUB, because that will show, right, on X-ray, you can see the stent, and if
the proximal portion of the stent is not curled, then they'll probably need additional imaging,
such as a renal ultrasound or a CT scan. But that's a pretty an easy screening tool is just a bedside
abdominal X-ray to check the stent position. So, that's one thing. Of course, discomfort, I'm sure
you also have seen these patients, and particularly with the urearyal stents, while they don't have
a urine bag out of their flank, which is nice, urearyal stents tend to be far more uncomfortable
than a percutaneous nephrostomy, and these people feel like they need to pee all the time, even when
their bladder is empty, right, because they have something irritating their inside of their bladder,
or they can even have flank pain with voiding. So, once they're fully is out and they're
voiding, they can have flank pain with voiding, because actually, as you increase that
intravesical pressure, so as you increase the pressure in your bladder with voiding, you can actually
have reflex up the stent, which can cause distension of the renal pelvis and pain, right, and that's
because that's an interesting thing, right, you're in the vast majority of adults who do not have,
you know, we have a mechanism that prevents reflex of urine back in here, Kitty,
when you avoid, but the stent, unfortunately, keeps that open and doesn't prevent that reflex. So,
that's some considerations. You know, I mean, there's always like the surgical issues, right, so,
I mean, there are specific instances where somebody places the stent incorrectly and the stent,
you know, the proximal portion of the stent is outside of the kidney, or within the renal
perencoma, those things are very uncommon, but they can happen. Of course, there could be injury,
you know, to the bladder or, you know, or again, those things are very uncommon. Brian, questions,
thoughts? So, you mentioned the temporary stent. Are there some that sustain forever then?
No, these all eventually come out. Okay, all right. Yeah, if there's somebody with a chronic or
permanent need for decompression, right, a chronic or permanent need for a stent or a,
or a nephosphate tube, we have to coordinate as on an outpatient basis them, having that changed
every three months about, which, which does happen. So, I've had patients who, let's say, have
hydronephrosis due to dreaded obstruction from cancer, right? And that person comes to my,
usually, exchanges in the clinic, actually, and I've had a number of patients that I'm just very
good friends with, and they come to my office every three months forever, and I change their stents.
So, yes, and I just mentioned that because I think a lot of, at least particularly lay people,
when they think of stents, they think of cardiac stents, which, yeah, which are just very different.
Now, when these are removed, so we don't get a whole lot of primary urology patients in the sick
you, but every so often, I will get a call from urology, hey, we've got this patient coming out
of the operating room, they are kind of hypotensive, they don't look so great, we'd like to put them
in the ICU kind of overnight for monitoring, and it's almost always removal of a ureteral stent,
and they end up being kind of mildly septic, maybe really septic, and then, you know, we kind of
nurse them for a day or so, and they get better, and they always do fine. Is this something that's
common? Like, I don't mean to say we get this a lot, right? But it just feels like it's common
enough that if I ever get a call from urology, I can are pretty much predict this is going to be the
problem. We, you know, remove the stents, let's say somebody had a kidney stone surgery,
a ureteroscopy, right? So, we went in their ureter or the camera, we blasted the stone,
that's usually an outpatient procedure, the patient goes home with a stent,
and then they come back to our clinic, we pull out the stent in the clinic typically,
which is a very quick procedure, but again, yes, if that stent is colonized with bacteria,
potentially the manipulation has stirred something up, and then that person calls back our
clinic later, that day and says, hey, I have a fever, right? And that's potentially the person,
I mean, that's a person here, like, maybe you need to go to the ER and get evaluated and then
that person, obviously, if they're, if they're having that substance picture, then, you know,
have to get admitted and then we're calling you. And typically it's because they're stent
in that period of time, whether it's one week, two weeks, a month, two months, since their
stone procedure, you know, has had colonization of that stent, and so we're manipulating something.
You know, typically if somebody's had a stent in for a number of weeks before we manipulate it,
then we're trying to get a urine sample before we manipulate it and remove it, you know,
to make sure that they don't necessarily have an infection. And definitely, whenever I pull out
stents in the clinic, I do pre-medicate with an antibiotic. So there are a lot of, you know,
there are a lot of surgical procedures that don't need antibiotics, and of course, I'm a very
strong believer. I'm not overutilizing antibiotics, but stem removals, we always give, you know,
an oral antibiotic in the office, or if they have a history of a complex organism or multi-drug
resistant organism, you know, sometimes we're giving like, you know, an intramuscular tober mice in
in the clinic before they have that stent removed. So there's a lot of things we can do, you know,
to prevent that from happening, but it's not impossible. Sure. Sure. And, you know, I say this a
lot to people who work in the ICU, right? We see a unbalanced subset of patients, right? We sort
of get this impression that, God, every time they take a stent out of somebody, they get
seriously septic. When in reality, it's, that's the only time you guys call us, right? So,
yeah, we see five of these a year maybe, like, but it just, it does feel like, hey, that's
something we commonly see. So, but yeah, that doesn't sound like it's common in the grand scheme of
things. Final thoughts, anything else that you want critical care folks to know about this disease,
actually? If somebody's coming in obviously with like new onset renal failure, people always
consider urinary retention, but sometimes there's an upper tract component as well. So, you know,
if they come in with a grossly elevated creatine, and let's say they get a bladder ultrasound,
and the bladder is not, not full, then, you know, it still is worth additional imaging to make sure
that they don't have something like stones. And I have seen, you know, that sounds like that's a
zebra, but there are people who have come in, and you're with an elevated creatine, and they have
bilateral, irritable stones. So, you know, it certainly can happen, and that's something that before
they end up with, you know, a dialysis catheter, you know, if they, if they need bilateral stents,
that's a, that's a much more optimal outcome. So, it can rarely happen, but I'd say always consider
the upper urinary tract, you know, for those, for those patients as well.
Thank you so much for joining us. I remember everyone. These have just been our own opinions,
not those are our employers, and just general educational content, not medical advice. I will talk
to you guys next time.