{"id":4792,"date":"2020-06-22T14:53:10","date_gmt":"2020-06-22T14:53:10","guid":{"rendered":"http:\/\/edren.org\/ren\/?page_id=4792"},"modified":"2020-08-17T11:28:34","modified_gmt":"2020-08-17T11:28:34","slug":"aki-case","status":"publish","type":"page","link":"https:\/\/edren.org\/ren\/education\/aki-cases\/aki-case\/","title":{"rendered":"AKI Case &#8211; Low Urine Output"},"content":{"rendered":"\n<p>You are the FY1 on the orthopaedic ward. A 64-year-old lady was admitted to hospital for an elective right total hip replacement. The operation goes to plan with no complications. However, 4 hours after her return to the ward she still hasn\u2019t passed any urine. You are bleeped by the nurses to come and assess her.<\/p>\n\n\n\n<p>You go to see her and start to take a focussed history. <\/p>\n\n\n\n<p class=\"has-text-color has-medium-font-size\" style=\"color:#ee1225\"><strong>What questions would you like to ask her?<\/strong><\/p>\n\n\n\n<p><em>Write down your answers prior to checking with our suggestions<\/em><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-40812\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Questions<\/strong><\/button><div id=\"ac-40812\" class=\"c-accordion__content\">\n<div class=\"wp-block-group has-background\" style=\"background-color:#ebebeb\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p>When did she last pass urine?<\/p>\n\n\n\n<p>Does she have a catheter in \u2013 long term or for operation?<\/p>\n\n\n\n<p>How much fluid has she drunk over last day?<\/p>\n\n\n\n<p>When was she fasting from?<\/p>\n\n\n\n<p>When did she stop clear fluids?<\/p>\n\n\n\n<p>How has she been recently \u2013 well vs. unwell?<\/p>\n\n\n\n<p>Does she have any past medical history: diabetes, hypertension, systemic disease e.g. lupus?<\/p>\n\n\n\n<p>Any family history of renal disease?<\/p>\n<\/div><\/div>\n\n\n\n<p><\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-15901\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Answers<\/strong><\/button><div id=\"ac-15901\" class=\"c-accordion__content\">\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p class=\"has-background\" style=\"background-color:#efefef\">She thinks she last passed urine this morning before the surgery. She fasted from midnight and stopped clear fluids from 6am but thinks she had her last drink, a cup of tea, at about 9pm. She has not had any IV fluids. She has felt well recently. Her past medical history: T2DM, which is diet controlled and is well controlled. No relevant family history.<\/p>\n<\/div><\/div>\n\n\n\n<p>&nbsp;<\/p>\n<\/div><\/div>\n<\/div><\/div>\n\n\n\n<p>Another important question to ask is medication history. <\/p>\n\n\n\n<p class=\"has-text-color has-medium-font-size\" style=\"color:#ec1212\"><strong>Can you list any medications which may lead to renal impairment in the context of surgery?<\/strong><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-32526\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Medications<\/strong><\/button><div id=\"ac-32526\" class=\"c-accordion__content\">\n<p class=\"has-background\" style=\"background-color:#efefef\">&#8211; NSAIDS<br>&#8211; ACE -inhibitors, ARBs<br>&#8211; Diuretics<br>-Metformin and other hypoglycaemic medication<\/p>\n<\/div><\/div>\n\n\n\n<p>&nbsp;<\/p>\n\n\n\n<p>This lady has only been taking paracetamol as required for pain. You move on to examine her<\/p>\n\n\n\n<p class=\"has-text-color has-medium-font-size\" style=\"color:#f01313\"><strong>What would you be looking for in your examination and what investigations would you like?<\/strong><\/p>\n\n\n\n<p><em>For each of these, try to write your own lists before revealing the answers<\/em><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-39179\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Examination<\/strong><\/button><div id=\"ac-39179\" class=\"c-accordion__content\">\n<div class=\"wp-block-group has-background\" style=\"background-color:#e9e9e9\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p>As with all patients &#8211; if your patient was unstable start an A-E assessment and escalate as appropriately.<\/p>\n\n\n\n<p>As she is currently stable<\/p>\n\n\n\n<ol class=\"wp-block-list\" type=\"a\"><li>Check catheter \u2013 kinked, patent, draining, volume?<\/li><li>Assess fluid status: &nbsp;mucous membranes, JVP, pulse (rate and volume), skin turgor, oedema \u2013 peripheral and sacral, hypotension is a late sign<\/li><li>Fluid replacement &#8211; has she had any? What rate?<\/li><li>Abdo \/ renal exam \u2013 any tenderness?<\/li><li>Examination of any wounds, drains etc<\/li><\/ol>\n<\/div><\/div>\n\n\n\n<p>&nbsp;<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-39796\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Investigations<\/strong><\/button><div id=\"ac-39796\" class=\"c-accordion__content\">\n<p>&nbsp;<\/p>\n\n\n\n<div class=\"wp-block-group has-background\" style=\"background-color:#e8e8e8\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p>Observations &#8211; repeat these currently and compare to those pre-operatively and intra-operatively &#8211; looking at intra-operative observations may indicate hypotension in the operation or the degree of change between them may indicate potential causes for presentation<\/p>\n\n\n\n<p>Blood tests &#8211; repeat bloods if possible and compare values to pre-operative values. Especially U+Es (creatinine rise? , dehydration?) and full blood count (bleeding? , hypovolaemia?)<\/p>\n\n\n\n<p>Further investigations will depend on what you find in your examination<\/p>\n<\/div><\/div>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p>Returning to your patient<\/p>\n\n\n\n<p>&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"1024\" height=\"590\" src=\"http:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/06\/fluid-review-1024x590.png\" alt=\"\" class=\"wp-image-4798\" srcset=\"https:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/06\/fluid-review-1024x590.png 1024w, https:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/06\/fluid-review-300x173.png 300w, https:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/06\/fluid-review-768x442.png 768w, https:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/06\/fluid-review-150x86.png 150w, https:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/06\/fluid-review.png 1214w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/figure>\n<\/div><\/div>\n\n\n\n<p>&nbsp;<\/p>\n\n\n\n<p>You decide that you need to take some further action for Mrs Fake Patient<\/p>\n\n\n\n<p class=\"has-text-color has-medium-font-size\" style=\"color:#f01111\"><strong>Select what you feel describes the best action<\/strong><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-41713\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Do nothing<\/strong><\/button><div id=\"ac-41713\" class=\"c-accordion__content\">\n<p class=\"has-background\" style=\"background-color:#e5e5e5\">This is not the best option here and in fact may cause your patient to further deteriorate and become sicker.<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-81267\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>IV fluids<\/strong><\/button><div id=\"ac-81267\" class=\"c-accordion__content\">\n<p class=\"has-background\" style=\"background-color:#e1e2e3\">Yes fluid is correct. There may be another answer that is pertinent.<\/p>\n\n\n\n<p>&nbsp;<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-56527\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Blood<\/strong><\/button><div id=\"ac-56527\" class=\"c-accordion__content\">\n<p class=\"has-background\" style=\"background-color:#d3d3d3\">Although we do not have haematology results back, there is no evidence of acute bleeding presently. Therefore this is not the most appropriate answer.<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-49378\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Continuous review<\/strong><\/button><div id=\"ac-49378\" class=\"c-accordion__content\">\n<p class=\"has-background\" style=\"background-color:#dedede\">Correct. This is the only way we can determine whether any intervention is of any benefit in this situation and indeed any situation where a patient has deteriorated.<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-6798\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Anaesthetic review and reversal of spinal <\/strong><\/button><div id=\"ac-6798\" class=\"c-accordion__content\">\n<p class=\"has-background\" style=\"background-color:#dddddd\">This is not required. Mrs Fake Patient can feel and wiggle her toes. If there was ongoing dense paresis then this could be considered<\/p>\n<\/div><\/div>\n\n\n\n<p>&nbsp;<\/p>\n\n\n\n<p>On a piece of paper prescribe the type of fluid and rate at which you would prescribe it, then select reveal when you have completed this.<\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-56671\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Reveal<\/strong><\/button><div id=\"ac-56671\" class=\"c-accordion__content\">\n<p class=\"has-background\" style=\"background-color:#dddddd\">500ml of any crystalloid as a bolus (rate 999mls\/hr). Then reassess.<\/p>\n<\/div><\/div>\n\n\n\n<p>&nbsp;<\/p>\n\n\n\n<p>With this treatment her heart rate stabilises to 72bpm and BP comes up to 134\/76. You determine that she is intravascularly deplete likely due to dehydration following prolonged fasting. You decide to prescribe some further background intravenous fluids and encourage Mrs Patient to drink.<\/p>\n\n\n\n<p>You ask that a strict fluid balance be recorded and plan to review her later in the day.<\/p>\n\n\n\n<p>You review her and prescribe a further bag of fluids. On further review later that day you see that she has passed 237ml of urine in 3hours.<\/p>\n\n\n\n<p class=\"has-text-color has-medium-font-size\" style=\"color:#e51616\"><strong>Is this sufficient for this lady? How would you determine this?<\/strong><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-77909\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Answer<\/strong><\/button><div id=\"ac-77909\" class=\"c-accordion__content\">\n<p class=\"has-background\" style=\"background-color:#dbdbdb\">Yes. Aim for 1ml\/kg\/hour. If we say the average woman is 60-70kg then that would be 60-70ml\/hr (180 &#8211; 210ml over 3 hours).<\/p>\n<\/div><\/div>\n\n\n\n<p>&nbsp;<\/p>\n\n\n\n<p>Mrs Patient&#8217;s urine output returns to normal over 24 hours and the rest of her admission is uneventful. She completes her physio and is discharged without further complications. You determine her initial low output was due to dehydration and encourage her to increase her oral fluid intake.<\/p>\n\n\n\n<p>Well done you have completed the case.<\/p>\n\n\n\n<p>&nbsp;<\/p>\n\n\n\n<p>Further resources<\/p>\n\n\n\n<p><a href=\"http:\/\/how-to-complete-a-fluid-assessment\" class=\"ek-link\">How to complete a fluid review.<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>You are the FY1 on the orthopaedic ward. A 64-year-old lady was admitted to hospital for an elective right total hip replacement. The operation goes to plan with no complications. However, 4 hours after her return to the ward she still hasn\u2019t passed any urine. You are bleeped by the\u2026<\/p>\n<p> <a class=\"continue-reading-link\" href=\"https:\/\/edren.org\/ren\/education\/aki-cases\/aki-case\/\"><span>Continue reading<\/span><i class=\"crycon-right-dir\"><\/i><\/a> <\/p>\n","protected":false},"author":7,"featured_media":0,"parent":4106,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"class_list":["post-4792","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4792","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/comments?post=4792"}],"version-history":[{"count":29,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4792\/revisions"}],"predecessor-version":[{"id":5068,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4792\/revisions\/5068"}],"up":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4106"}],"wp:attachment":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/media?parent=4792"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}