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Discussion

Increasing creatinine

Pt is 74 yo with a hx of a parotid tumor that mets to the spine, "kidney insufficiency" (as reported by the patient),baseline cr seemed to be 1.09 and htn. Had a two stage back surgery something like T10 to pelvis. The second stage was aborted X 2 due to a fib with rvr.

She finally has her second stage after being on amio and metoprolol.

Ebl is 4500, received 10 units prbcs plus some coags, a few liters of colloid etc... She was hypotensive to the 60 sbp in the or at times.

Post op day 1 receives 2 prbcs, 2 cryo and was Extubated. Cr is 1.20. Makes the minimum of 30ml/hr all day. No hypotension overnight receives 2 more of prbcs plus some albumin. Cr post op day 2 is 1.39. Urine output dwindles overnight and makes 5-20ml/hr.

My question is, I suggested lasix in the morning and was denied. Afternoon Chem is 1.39 and cvps are greater than 20. Urine out put remains 15ml an hour and then the attending rounds and said it's Ok to give lasix.

Is lasix the right or wrong choice her? Do we let her be oliguric until her kidneys kick back in? Again I gave her two prbcs plus 500 of albumin with no pick up in urine output.

Mike

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    Do you have a urine Na by chance?

    The use of Lasix in AKI can be controversial in some depending on the degree of AKI that is present. It can also be an issue of giving Lasix in hopes that the kidneys pick back up instead of determining the etiology and treatment plan for the AKI.

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    • Author

    We sent one. I don't remember, serum na was normal though.

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    Not that it's a good answer, but did the lasix increase her UO? If so, then it was the right choice for her.

    I look at your patient Ike this...she was severely hypotension in OR. Kidneys are the most susceptible organ to hypoperfusion. Her kidneys took a hit during that. AND, not only did she have poor perfusion, but her hemoglobin was also probably low after the EBL of 4500 (holy crap) leading to poor oxygen delivery to her kidneys. Now you've hit 2/3 things that lead to organ damage. If she had any oxygenation issues, you'd hit a 3rd. Once damaged, sometimes the kidneys take a few to reflect the damage and no matter what you do, the kidneys need to heal and the only thing you can do is maintain good perfusion, oxygenation, and O2 delivery (hgb), and play the waiting game. Lasix is good for vascular volume overload as you know, which it appears this patient may have developed given the high CVP. I'd assume they would also check her I&Os (she has gotten like 15 blood products and has damaged kidneys so I would assume she'd be positive). So yeah, Lasix doesn't sound like a bad idea although it's not going to do much for the kidneys.

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    • Author

    Lasix immediately help here urine output. 400 in about 2 hours. Great input... She was definitely +a few liters since the or and had pulmonary edema on chest xray.

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    • Author

    Pts cr peaked the next day at 1.44, she's auto diuresing and cr is back to baseline.

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    Did you mean an EBL of 450. She prob has more than AKI with a 4500 EBL. I agree it takes a few days for the kidneys to start working again. Sounds like things are starting to turn if she had a good response to the Lasix. Worse case scenario she starts dialysis until renal function returns.

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    • Author

    No I meant 4.5 liters. Not uncommon and not the most I've seen. I've had a patient that required 90+units of products... But that's another story.

    Her urine out put increased after the lasix and then patient started auto diuresing the next day or so. Cr peaked and then down trended to baseline. She did well.

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