Septic shock from obstructive pyelonephritis in an older diabetic man

Presentation

A 68-year-old man with type 2 diabetes, hypertension, and benign prostatic hypertrophy is brought to the emergency department by his wife. Over twenty-four hours he has become febrile, confused, and anuric, with two days of dysuria and loin pain preceding a rigor this morning. On arrival he is peripherally mottled, breathing at 28/min, heart rate 124/min, blood pressure 78/46 mmHg, and oxygen saturation 92% on room air. A venous blood gas shows pH 7.22, bicarbonate 14 mmol/L, base excess −11, and lactate 6.0 mmol/L.

The single most important recognition here is septic shock: he is hypotensive, his lactate is markedly raised, and he has a clear source. He meets the Sepsis-3 definition — vasopressor-dependent (or persistently) hypotension and hyperlactataemia after adequate fluid, with an in-hospital mortality that exceeds 40%.^[1] Every minute from now matters.^[3]