Post hemorrhagic renal failure
Patient presentation:
A 41-year-old female was admitted for scheduled laparoscopic hysterectomy with salpingectomy and oophorectomy for treatment of endometrial cancer. The laparoscopy was difficult due to patient habitus (5’4”, 250#) and during the procedure, a blood vessel was nicked. Bleeding was unable to be controlled through the laparoscopic incisions. Because of the volume of blood being lost and the need to control bleeding quickly, a vertical midline incision was made extending from the pubis nearly to the xiphoid process. The source of bleeding was determined and repaired, but the patient had already suffered extensive blood loss. Blood transfusions had been started before the abdomen was opened; EBL (estimated blood loss) was 5L (this includes, of course, blood that was transfused and then subsequently lost). The patient also received NS wide-open in an effort to maintain fluid volume and blood pressure. Unfortunately, the patient arrested while in the OR; CPR was initiated and, with defibrillation, was successful. The patient was stabilized, her incisions were closed and she was transferred to the SICU postoperatively. Postop, it was noted that the patient was anuric. This did not correct with fluid bolus and bedside bladder scans were negative for urine retention (the patient had a Foley in place, so retention would have been unlikely). Labs revealed elevated BUN and creatinine; these would rise over the next day to a high of BUN 115 and creatinine 7.0. A nephrology consult was ordered stat; the patient had a renal ultrasound, KUB (kidney-ureter-bladder), and abdominal CT in addition to the labs. It was determined that the patient was in ARF secondary to fluid loss/imbalance and the extended period of decreased renal blood flow during surgery and the code.
Treatment:
A subclavian venous catheter was inserted in order to begin dialysis. Initially, the patient was dialyzed for four to six hours every day. The patient was put on a strict renal diet (low sodium, potassium, and phosphorus) with a 1000 mL/day fluid restriction. PhosLo® (calcium acetate) 1334 mg was given with each meal. The patient was placed on strict I&O and the Foley was left in place in order to obtain accurate output measurements. She remained severely oliguric for almost two weeks with a max daily urine output of 15 mL. Vital signs were taken every four hours, and blood was drawn daily to assess BUN, creatinine, GFR, WBCs, H/H. The patient was anemic secondary to blood loss with H/H 7-9/22-25 in the first three days postop. She was given a total of ten units of blood by postop day four, in addition to the blood administered during surgery. Due to the trauma sustained during surgery, the patient was initially very weak and unable to walk or sit up for long periods. Physical therapy was started as soon as the patient was transferred from SICU to a medical floor (four days postop).
Outcome:
After two weeks in the hospital, the dialysis schedule was changed to every other day and finally a typical three days-per-week schedule was attained. During the course of her hospital stay, the patient’s BUN and creatinine gradually decreased. After two weeks in the hospital, her urine output increased from ≤ 15 mL to 100 mL/shift and finally reached near-normal levels. At the time of discharge, the patient was able to walk with a walker over two hundred feet and sat up in a chair most of the day. After three weeks she was discharged to a rehab center to continue extensive physical therapy and dialysis. It was expected that her renal function would return and she would eventually be able to stop dialysis.
Case created by Jessica Fehr, 2010.