Acute Renal Failure - Post Surgical Bleed
Patient Presentation:
Patient B.K. presented to the ER with complaints of severe abdominal pain with nausea and vomiting for the last 2 days. She had been studying for finals but could not shake the terrible pain in her RLQ. It was noted very quickly that her appendix had ruptured. She was rushed to the OR to have emergency surgery to have her appendix removed. During the emergent surgery B.K. lost about 1.5 liters of blood and was kept intubated for airway protection. She was transfused with 5 units of packed red blood cells (PRBCs) in the OR and was transferred to the ICU post op. A foley catheter was placed to monitor urine output. B.K.’s vital signs were BP 92/48, HR 124, RR 22, Oral temperature 38.6 °Celsius, O2 sat 96% on ventilator support FiO2 70%, RR 18 (breathing 2-4 over the vent), TV 450 and PEEP 5.
Labs/Tests:
Hgb 6.9, Hct 18.7, WBC 20.6, BUN 26, Cr 2.8
Coags and LFT’s WNL
EKG: Sinus Tachycardia
Blood cultures, urine cultures and sputum cultures sent
Differential Diagnosis:
Appendicitis, Sepsis, Hypovolemic Shock, Acute Renal Failure
Treatment:
Post-op B.K. was diagnosed with acute renal failure secondary to hypovolemic shock from a ruptured appendix. She was transfused PRBCs to maintain Hgb greater than 10 and had repeat CBC’s and BMP’s sent every 4 hours to monitor lab values. She was started on broad-spectrum antibiotics for infection coverage until her culture results were received. B.K. was given fluid boluses of NS (totaling 2 liters) due to dehydration and poor urine output, but her output continued to remain less than 10ml an hour of concentrated dark amber urine. On day 2 post-op B.K. was extubated and tolerating 2L NC with O2 sat of 97%. Nephrology was consulted to assess B.K.’s need for dialysis due to decreased urine output and elevated BUN and Cr levels. A RIJ Quinton catheter was placed at the bedside and hemodialysis was initiated immediately after. She was responding well to antibiotic coverage for her ruptured appendix and remained afebrile with no culture growth as of day 3.
Outcome:
B.K. received hemodialysis treatments every other day for 10 days and began to show improvement in her BUN and Cr respectively. Her urine output began to increase with clear yellow urine about 30-50ml/hour. Dialysis was discontinued and B.K’s Quinton catheter was removed. She was discharged to home and told to follow up with nephrology and her primary care physician in the following weeks.