Low Urine Output Following Suburethral sling placement

[anastasia158]

Scenario: MY patient was one day post suburethreal sling placement. From 6 am to 10 am on day two - and proir to removal of lady partsl packing and bladder trial - she was only able to empty 50 cc of urine in a four hour period via foley catheter. During shift report I was also notified that the urine output post op was low.

My nursing instructor freaked out on me because she said I should have recognized patient's low output as a priority nursing problem to be addressed. She went on to tell me that with this piece of data alone - she feared the patient was going into kidney failure and that most likely we would not be removing foley that day but that patient would have to be d/c'd with it as the doc would want to closely monitor every bit of output due to suspected kidney failure. She also freaked because she said I should have been emptying foley q hr and recording.

My instructor then did a bladder scan which showed 0 cc of urine in her bladder. I am not sure my instructor did this correctly as the icon of the four quadrants of the bladder appeared entirely black. I was always told that you need to see black in all four quadrants and that will tell you you are in the proper site to do the reading.

FYI BUN and creat were within normal limits.

Anyway, my question is-- is it normal to have a low urine output post suburethreal sling placement prior to removal of vag packing and bladder trial. Was it appropriate for my instructor to suspect kidney failure based on the urine outout alone so early after surgery?

Thank you for your advice.

[LobotRN, BSN, RN]

I think the bigger picture here that your instructor was rightfully concerned about was a potential fluid volume deficit post surgery that was setting up your pt for kidney injury. What were the vitals? If the BP was lo and the P elevated, then the kidneys don't have enough pressure (secondary to low circulating volume) to produce filtrate while wastes are accumulating (next organ to be hit after kidneys >>> BRAIN!). In this situation, you pt would likely have needed a fluid bolus to restore volume (possibly blood if H/H is low and/or there was significant blood loss peripoperatively). BUN and creatinine will be normal for a period of time, but when the filtration process slows significantly or stops, then you will see distinct changes in those values.

I'm going to hazard a guess here and suppose that you are seeing a link between the bladder sling placement and the urine production, but the situation is broader than that. A bladder in need of sling placement means that the collection vessel is ill placed in the abdominal cavity and needs intervention, but there is no indication here that the pt had kidney difficulty or problems with the production of urine. The more relevant link is that the client underwent surgery and post had low urine output. That speaks to a broader issue of circulating volumes and tissue perfusion. Therefore, if the kidneys aren't producing enough urine, that tells you that they 1) don't have circulating volume and pressure to do the job, and 2) if indeed volume and pressure are low (which happens post any surgery if not managed), the kidneys themselves are at risk for ischemia which leads to necrosis if not corrected. BLAMMO! Acute kidney injury....

The rule of thumb post any kind of surgery is to monitor urine output and vitals. Many pts are in a fluid deficit of some sort post surgery (NPO status prior to surgery and no fluids running until they show up in pre-op), and if it is severe enough, those delicate little kidneys are the first to be injured. Any production less than 30 mL/hr is, in my book, cause for a rapid focused assessment and a call to the doc for orders.

Also keep in mind that profuse production of urine post operatively can also mean kidney compromise. I had a pt that was producing over 600mL/hr (after I emptied the foley twice in three hours, I went and got my instructor. Something wasn't right, and I didn't know how to approach it). Everyone was saying, "GREAT urine production!" BUT...pt had lo BP and elevated pulse! So, her kidneys had lost all ability to be selective and could no longer concentrate urine, which leads to profuse diuresis, fluid volume deficit, lo BP and increased P, and kidney damage. That one sticks with me to this day, and my instructor back then said something that also lasts with me to this day. "When you have a clinical situation, take it back to a broader physiological process so you can determine the risk and prioritize. Is it perfusion? What is at risk with low perfusion? Is it low perfusion to one area like an extremity? Is it pressure? What is at risk with lo pressure? High pressure? Is this a systemic pressure issue, a local pressure issue? Is it high pressure in the vascular space? Hi pressure in the intracranial space?"

Hope this helps.

[nerdtonurse?, BSN, RN]

I work in ICU, and we get people post surgery. If I only saw a 50cc output in a 4 hour period, my first thought wouldn't be kidney failure with a normal BUN and creatinine and an empty bladder.

I'd be worried about bleeding.

If you've got someone who's not had issues before, and they suddenly stop making urine, ask WHY. Was the BP low -- and by that, I mean was the MAP below 60 and staying there? Were they getting fluid replacement? If she's been getting LR at 100cc/hr, or D51/2NS at 75, she should have been peeing like a racehorse. I'd have been on the phone for a stat H/H, got orders for a fluid challenge, made sure there was a doc sitting out on the end of that limb with me in case the patient starts going down the tubes. How did she look? Skin cool and clammy, a little pale? Skin hot and dry?.

If she was saline locked, I'd have been looking at her fluid intake -- did she get dehydrated, and just too nauseated after surgery to want to drink?

Something's not right. Just use the rule my preceptor taught me:

"Your patient's job is to die on you. What's the easiest way for them to do it? Figure it out, and stop it." In this case, you have a post op. What's the easiest ways for someone who's been cut on to die on you -- bleed out, or go septic.

[LobotRN, BSN, RN]

Ooooh yeah! Bleeding! D'oh! :icon_roll

[traumaRUs, MSN, APRN]

Moving to nursing student assistance forum.

[nurseprnRN, BSN, RN]

oh, yeah. 50cc in four hours is only ok if you weigh less than ten kilos :) why are those kidneys not making urine?

your instructor was upset because of all the things these folks are saying to you. next time, don't wait more than an hour to report this lack of normal renal behavior to the physician. check iv and other intake (and don't forget to check the anesthesia record, since that will tell you about fluids and vs during anesthesia) and the pacu record (ditto); the physician will be interested in those data when you call.

i'd be suspicious of a bun and creatinine report so soon after surgery. i mean, were they drawn after the patient returned to the floor with stat reporting... or were they her preops?

whatever happened to this lady after all this?

[NurseOnAMotorcycle, ASN, RN]

We see a lot of TVT and suburethral sling pts. As a norm, GYN pts are very very dry. The reason is that they do the bowel prep the night before and are NPO. The water is being taken from them but not replaced.

We encourage clears and have the IVs going at a good clip postoperatively. With a UOP that low, I'd be looking at bladder scanning (which you did), blood pressures and heart rates, checking abdomens for softness (bleeding). Most likely, the MD would want her to be bolused with fluids.

Added: watch for lightheadedness/fainting with ambulation. Orthostatic drops in BP happen often with GYN pts as does vasovagal syncope.