The nature or etiology of the patient’s presentation to the operating room is an important factor for formulation of the anesthetic plan. The patient with pyelonephritis may present for emergent surgical intervention to rectify any of several conditions, such as emphysematous pyelonephritis or cystitis, phrenic abscess, or xanthogranulomatous pyelonephritis (see Complications above). The patient may be significantly febrile and dehydrated. Dehydration may result from the accompanying nausea and vomiting. Antibiotic therapy may be ongoing, and the anesthetist must be vigilant to adhere to the administration schedule for the antibiotics. Electrolyte imbalances, particularly potassium, are to be expected and may be partially the result of the significant emesis the patient may have. Both electrolyte concentrations and fluid balance should be determined preoperatively and corrective measures initiated as soon as possible. The patient may be septic, depending on the emergent condition precipitating the surgical intervention. The anesthetist should induce general anesthesia using the classic rapid sequence technique.

The anesthetist must ensure adequate intravenous access. Ideally, two large-bore IV catheters would be started before anesthesia to initiate adequate fluid resuscitation, maintain antibiotic administration schedule, and/or administer any vasopressors or vasoactive medications that may be required. Significantly febrile patients may require active cooling measures. The anesthetist may need to administer cooled IV fluid, apply cool packs to the axillae and/or groin, and use a forced-air cooling blanket to reduce the patient’s temperature.

Frequently, the patient with pyelonephritis presenting emergently to the operating room requires complete or partial nephrectomy. As such, it may be necessary to place the patient in a lateral decubitus position. The anesthetist must take care to ensure proper positioning of the patient to prevent potential nerve injury. The anesthetist must also be acutely aware of the patient’s respiratory status, especially the presence of any pulmonary co-morbidity factors that may be exacerbated by placing the patient in a lateral decubitus position. For example, pneumonia in a lobe of the dependent lung in the lateral position may reduce gas exchange and/or exacerbate any shunting that may be present.