Pt was s/p abd surgery POD > 5 when they stopped producing urine. Less than 10cc/hr x 24hrs. Pt had a foley cath, was bladder scanned, negligent amount of urine in the bladder. multiple fluid boluses failed to produce any result, CT was negative as to the fluid being in abd/pelvis, pt was not overly edematous, lung sounds were diminished but clear, BUN/Creatnine were mildly elevated, but nothing serious, majority of other labs were WNL, only major change was an elevated phos. VS were hypotensive-normal, tachycardic, afebrile, resp even, shallow, regular. Pt had previously had no renal problems.
Pt was on a lot of narcotics for pain issues (the only thing that was changed within 48 hours) and was somewhat sedated.
The CT was done without contrast, alb/pre-alb were WNL, HCT was unchanged from POD 1 despite small decrease (assuming dilutional), serum uric acid WNL, (as previously stated UA/urine lytes I dont know same goes for renal US results).
I did hold the heparin that was ordered for DVT prophylaxis post-op, pt had not received any NSAIDs or diuretics.
The EBL from surgery was
Pt was not diabetic, no PMH other than that which required the surgery.
Dr did not order low-dose dopamine for the patient.
All in all I generally just was looking for further avenues I should have explored while caring for this "patient". I did and suggested everything I could think of to the doctor and the rapid response team. I am a fairly new nurse, although try to pride myself on my critical thinking and thoroughness, working med-surg this should have been a fairly uncomplicated post-op course and yet I am fairly completely befuddled as to what else I could have done and why the onset was so quick.
scoochy- If I am right about blood loss during surgery, HCT will start off looking normal, then drop rapidly as plasma recovers (and RBCs don't), taking about 10-11 days for HCT to actually return to normal. There should be no reason to estimate HCT, I am assuming (with a lot of things not mentioned) that PCV was counted and normal immediately after surgery. (found no bleeds, therefore likely to be from excessive loss during surgery Lv III-IV, supporting Hypovolemia, with resultant low renal perfusion, causing the kidneys to 'protect themselves'/'prerenal syndrome') Assuming the BP has gone from low to normal (which should be the case if there isn't an active bleed, or some major screw up from surgery like a forgotten clamp or using the kidneys for pin cushions, this should correct itself shortly).
Since this does appear to be a slightly late onset... there is the chance that we are seeing Vasomotor nephropathy due to any number of things, and if my DDX changes then I would start looking at severe sepsis from a nicked bowel or something similar.
Looks like I was pondering and posting while you were...
Renal blood flow is reduced during hypotension, and is restored by normalization of renal perfusion pressure.
If the patient's current renal dysfunction is caused by some impairment in the vasomotor control rather than some injury then normalization may be achieved by vasoconstrictor therapy.
PetiteOpRN
326 Posts
Eh, my money's on intra-abdominal hypertension/abdominal compartment syndrome.