Anuric post surgery, now what?

[frodo-dog]

OK, we learnt that the golden rule for urine was 30ml\hr. Armed with this information, I had clinicals today and stayed with my pt. She had colon reconstruction post cancer discovery. She has no kidney disease. She had a foley put in presurgery. When she arrived in pacu she had and maintained o2 96%, P 99, R 14, bp hovered around 75-85 \ 50 depending on whether she received morphine. Because her BP wouldnt rise and she really didnt regain consiousness, she stayed in pacu. Her normal bp was 110\70. During her time in surgery\pacu she received 3 L Na. NO URINE after 4 hours. Abdomen remained soft. There was no precipitous drop in BP or rise in R. She only lost 100ml blood during surgery. The pacu nurse did not do a bladder scan, or irrigate the foley. I did notice that the pt was mouth breathing with a nc. although if she nose breathed her o2 stats would remain at 96, her bp did rise into the mid 90's. Even so, the pacu nurse would not put the face mask back on saying that it was just a coincidence. Finally the hospatilist came over and sent the pt to icu. I couldnt follow her there.

But I felt totally unprepared in that I had learnt the golden urine rule, but not what to do? I am scared that after college I will know all the baseline information but not know how to react.

What do you do with this situation, what could be happening? No one could tell me on the floor. What should have been done for the pt have I have been the pacu nurse? :uhoh21:

[K+MgSO4, BSN]

30 ml an hour is NOT he golden rule! The Golden rule is .5mls per KG per hour How many of your patients are 60kgs??

So her SBP was 75-80mmHg. Was she cool peripherally? ( i would suggest drowsy if she was on the ward but so soon post op it is hard to tell) What does this suggest? That she was unable to maintain perfusion to all her organs and extremities and was perfusing only her core? her body would of shut down all other processes including urine production in order to maintain cerebral perfusion.

If she had still been in the PACU for X amount of time and had made no urine with a SBP that low I would have gotten her reviewed. I am sure that the PACU nurse felt that she had no one to call as the surgeon and anaesthist were probably in the next case and couldn't leave it.

3 L of IVT may not be a lot for a pt who has maybe had 4L of bowel prep the day before and been fasting for up to 12 hrs preop with no IV hydration.

A bladder scan may of been an idea but I doubt that it would of shown much urine in the bladder. Personally I am not in favour of irrigating catheters "just to see" if you have a non invasive way of checking a catheter patency with a bladder scan. It is just another way to bring infection into the body.

SaO2 of 96% are cool in my book. so few pt will have a SaO2 of 99 / 100%.

The hospitalist (an American term I am not familiar with am assuming ICU doc or medical registrar) saw her and sent her to ICU for IV filling and possible pressers. She was more than likely in acute renal failure.

If you were her PACU nurse you should of monitored her urine output hourly and notified someone after 2 hours of no output. However most pt will not stay in PACU for that long and it is often the ward nurses who pick up on these things. (happened to me last week with a emergency Hartmans procedure who recovered well then shut down 3 hours post op)

Your plan of action should be to assess vitals, interpret the results and plan your care based on the results no urine output for 2 hours call the medics and possibly get a set of bloods UE&C, FBC.

Hope that I am making sense because it is the end of my 5 days at work and I am at the bottom of my second G&T :-) further posters bear this in mind before pulling my post apart! :) :D

[Emergency RN]

Renal failure can be from a variety of reasons and rationales, and it is important to classify them according to their region of origin; ie. pre-renal, intra-renal, or post renal. Since the woman has no history of kidney disease, the likelihood that the cause is intra-renal is slim. Further, unless the foley has been in a very long time, I doubt that it would clot off or become blocked. Hence post-renal causation is probably just as unlikely for a fresh post op in the PACU.

That leaves, pre-renal. The questions that you ask yourself then, what renal perfusion issues are there? Volume (in this case, 3 liters instilled but where did it go?) if adequate (ie CVP?) should have raise the BP back to this pt's "normal." However, the pt is nowhere near that. So maybe it was a combination of the anesthesia, analgesics or third space that has kept her pressure (hence renal prefusion) low. Like Karenmaire stated, this is most likely a volume issue in relation to renal perfusion. If there is not enough intravascular volume, the kidneys will then shut down as there is nothing to filter. Give her more fluid until her CVP is normalized, then if still no urine, suggest a loop diuretic (Lasix) to the MD.

[Penelope_Pitstop, BSN, RN]

She sounds dry to me. Three liters isn't that much for the entire time in OR & PACU.

[OttawaRPN]

Dehydration? Hemorrhage? Shock? What did her labs show?

[frodo-dog]

Yes, she was dehydrated before surgery. Tenting and verbalizing thirst. I felt bad for her pre surgery because of that, but by the time I came on it was 1 hour before surgery and she had been NPO since midnight. So thank you for detailing that 3L is not much. I had thought that it was a lot and was wanting to check her lung sounds. Her foley only went in on the operating table.

So from what I am hearing, there is not much more that a nurse can do within scope bar monitor, watch for signs of problems and call the anesthetist and hospitalist (the doctor who works for the hospital as opposed to the pts GP who is no longer involved during the hospital stay) with an SBAR. I see my problem is defining nursing scope.

Thank you all for responding. A great help.

[XingtheBBB, BSN, RN]

So from what I am hearing, there is not much more that a nurse can do within scope bar monitor, watch for signs of problems and call the anesthetist and hospitalist (the doctor who works for the hospital as opposed to the pts GP who is no longer involved during the hospital stay) with an SBAR. I see my problem is defining nursing scope.

Thank you all for responding. A great help.

That BP was pretty low, pre-renal failure- failure to urinate caused by a problem before (pre) the kidneys. I'm only breaking that term down because sometimes people think "pre-renal" failure means something else, like early renal failure.

Sometimes a nurse has to call several times and firmly detail the situation. "The Pt BP is 72/50 MAP has been consitantly under 65 and she's not making urine, and she's not responding like she should be- her GCS is X". They need to hear a picture that shows them the same patient you see. Then know what you want and ask. Or at least have an idea and ask accordingly. "How about we try a fluid bolus? She doesn't have a hx of CHF and only had 3L of crystaloid" or "Should I give a bolus or do you think she needs some pressors?" Depends on the culture of the hospital and that PACU. How they are used to relating to their doctors.

Likely ICU ensured she had a CVP line placed, monitored fluid status, gave a couple fluid boluses and maintainace at 150ish, and maybe added a vasopressor like Dopamine, Phenylephrine, or Norepinephrine to boost that BP. THEN her kidneys can waste valuable fluid volume by making urine.