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Acute Renal Failure
Case Presentation
Ann Hayes, Sophia Loren, age 68, initially was admitted to the hospital for elective surgical
repair of an abdominal aortic aneurysm. Her surgery was documented as uneventful. However,
complications developed during her fifth postoperative day as a result of a small bowel
perforation.
Postoperative Day 5
Vital signs and laboratory results were as follows:
BP
170/94 mm Hg
HR
110 bpm
RR
30 Breaths/min
Temperature
38.6 C (101.4 F) rectal
Hgb
10.0 g/dl
Hct
30%
RBC’s
3.5 *10(6)/mm(3)
WBC’s
20,000/mm(3)
Urine tests showed the following:
Creatinine
0.6g/24 hr
Osmolarity
460 mOsm/kg
Specific Gravity
1.01
pH
9.0
Na+
45 mmol/L
K+
15 mmol/L
Cl48 mmol/L
Results of serum measurements were the following:
Na+
135 mmol/L
K+
4.8 mmol/L
Cl88 mmol/L
Ca++
6mg/dl
BUN
27 mg/dl
Creatinine
1.4 mg/dl
Uric Acid
9mg/dl
Phosphorus
5.2 mg/dl
Alkaline Phosphatase
14.8 units/dl
Laboratory results and vital signs were telephoned to her Nurse Practitioner. The Nurse
Practitioners orders included the following:
●
●
●
Hydralazine (Apresoline) at 10mg qid
Gentamicin sulfate (Garamycin) IV at 5mg/kg tid in divided doses
Piperacillin sodium (Pipracil) 3 g q 12 h
1
Gastrointestinal Fistula Repair
As a result of an abnormal abdominal x-ray film, Mrs. Hayes was returned to surgery for repair
of a small bowel perforation. Four days after Mrs. Hayes’s bowel surgery, she developed a
gastrointestinal fistula. She was again taken to surgery for repair of the fistula. Post operatively
her blood pressure dropped to 80/52 mm Hg and her urine output was 20 ml/hr, requiring
invasive monitoring. Mrs. Hayes’s oxygen saturations and arterial blood gas values dropped
significantly. She required intubation and was transferred to the intensive care unit (ICU).
Intensive Care Unit Admission
After Mrs. Hayes admission to the ICU, the staff took a complete history that revealed her
congestive heart failure. Mrs. Hayes weighed 76.5 kg (170lb) (preoperative weight was 71 kg
[158 lb]) and had 2+ pitting edema in her lower extremities. Her skin was pale, shiny, and dry.
She complained of nausea and stated that she “felt as if she had no energy left.” Fluid intake for
the past 24 hours was 1400 ml, and her output was 510 ml. Jugular vein distention was noted,
and crackles were auscultated bilaterally in the lung bases. The initial cardiac rhythm was
tachycardia with a rate of 110 bpm, a PR interval of 0.18 second, QRS complex of 0.14 second,
and peaked T waves.
A fluid challenge was administered unsuccessfully. Despite volume replacement and diuretics,
Mrs. Hayes’s renal status deteriorated further, and acute renal failure (ARF) was diagnosed.
Dopamine (Intropin) was started at 2 ug/kg/min and dobutamine (Dobutrex) at 3 ug/kg/min, and
continuous arteriovenous hemofiltration dialysis (CAVHD) was begun. Diagnostic data at this
time were the following:
Weight
BP
HR
Urine Output
Na+
K+
ClCa++
BUN
Creatinine
PAP
PAWP
82 kg (182 lb)
90/110 mm Hg (systolic)
124 bpm
15ml/hr
146 mmol/L
5.8 mmol/L
98 mmol/L
7 mg/dl
36 mg/dl
3.9 mg/dl
36/16 mm Hg
15 mm Hg
After 4 days of CAVHD, blood urea nitrogen (BUN) and creatinine levels began falling, and
blood pressure stabilized with a decrease in weight and edema. Electrolytes and laboratory
values returned to normal limits. Total parenteral nutrition (TPN) was begun, and renal function
continued to improve until CAVHD was discontinued 5 days later.
Questions (please include references)
1.
Discuss the pathophysiology involved in acute renal failure (ARF).
2.
Describe the four phases in the clinical course of ARF. The first phase of Acute Renal
failure is the onset phase. During this phase, kidney injury occurs.
2
3.
Compare and contrast oliguric and nonoliguric renal failure.
4.
What clinical assessment data support the diagnosis of ARF for Mrs. Hayes? What other
information may be useful in the diagnosis of ARF?
5.
What is the significance of the use of gentamicin sulfate (Garmaycin) and piperacillin
sodium (Pipracil) in Mrs. Hayes’s treatment regimen?
6.
Discuss the major nephrotoxic drug classifications, including risk factors and prevention
of nephrotoxicity.
7.
Discuss the major nephrotoxic drug classifications, including risk factors and prevention
of nephrotoxicity.
8.
What is the rationale for including dopamine (Inotropin) in Mrs. Hayes’s treatment plan?
9.
Identify other pharmacologic agents used in the treatment of ARF and the rationale for
their use.
10.
Discuss the dietary management of the patient with ARF.
11.
Discuss the three different forms of dialysis used in the treatment of ARF, including the
indications and contraindications for each. Why was CAVHD indicated for Mrs. Loren?
12.
List nursing diagnoses appropriate for care of the patient with ARF.
13.
What are the nursing responsibilities and potential complications related to continuous
renal replacement therapy (CRRT)?
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