Arf Case Study

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ARF Case Study

Acute Renal Failure Case Study

Directions: Please carefully read the following case study and answer the following questions in typed format. The resources that you will need to complete this case study include your textbook and drug book. Please include in text citations. This independent assignment is worth 25 points. Ann Hayes, 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 5th postoperative day as a result of a small bowel perforation.

Postoperative Day 5
Vital Signs|
B/P | 170/94 mmHg|
HR | 110 bpm|
Respirations | 30 breaths/min|
Temperature | 38.6 degrees|
Hgb | 10.1 g/dL|
Hct | 30%|
RBC’s | 3.5 x 106|
WBC’s | 20,000/mm3|
Urine Tests |
Creatinine | 0.6 g/24hr|
Osmolarity | 460 mOsm/kg|
Specific Gravity | 1.01|
pH | 9.0|
Na+ | 45mmol/L|
K+ | 15 mmol/L|
Cl- | 48 mmol/L|
Electrolyte Panel|
Na+ | 135 mmol/L|
K+ | 4.8 mmol/L|
Cl- | 88 mmol/L|
Ca++ | 6 mg/dL|
Creatinine | 1.4 mg/dL|
Uric acid | 9 mg/dL|
Phosphorous | 5.2 mg/dL|
Alkaline Phosphatase | 14.8|

Laboratory results and vital signs were telephoned to her physician. Her physician order’s included the following: Hydralazine (Apresoline) at 10 mg QID
Gentamicin Sulfate (Garamycin) IV at 5mg/kg TID in divided doses Piperacillin sodium (Pipracil) 3 grams every 12 hours
Gastrointestinal Fistula Repair
As a result of an abnormal abdominal X-ray film, Mrs. Hayes was returned to surgery for a 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 decreased to 80/52 mm Hg and her urine output was 20 mL/hr, requiring significant invasive monitoring. Mrs. Hayes’s oxygen saturations and arterial blood gas values decreased significantly. She required intubation and was transferred to the intensive care unit (ICU).

Intensive Care Unit Admission
After Mrs. Hayes’s admission to the ICU, the staff took a complete history that revealed her congestive heart failure. Mrs. Hayes weighed 76.5 kg (170 lb) (preoperative weight was 71 kg [158 lbs]) and had 2+ pitting edema in her lower extremities. Her skin is pale, shiny and dry. She complained of nausea and stated that she felt as if she had no energy left. Fluid intake in 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 (Inotropin) was started at 2mcg/kg/min and dobutamine (Dobutrex) at 3 mcg/kg/min and continuous renal replacement therapy (CRRT) dialysis was begun. Diagnostic data at this time were the following: Weight | 82 kg (182 lb)|

BP | 90-110 mm Hg (systolic)|
HR | 124 bpm|
Urine Output | 15 ml/hr|
Na+| 146 mmol/L|
K+ | 5.8 mmol/L|
Cl- | 98 mmol/L|
Ca++| 7 mg/dL|
BUN| 36 mg/dL|
Creatinine | 3.9 mg/dL|
PAP | 36/16 mm Hg (elevated)|
PAWP| 15 mm Hg (elevated)|

After 4 days of CRRT, blood urea nitrogen (BUN) and creatinine levels began falling, and blood pressure stabilized with a decrease in weight and edema. Electrolyte and laboratory values returned to normal limits. Total parenteral nutrition (TPN) was begun, and renal function continued to improve until CRRT was discontinued 5 days later.

1. Discuss the pathophysiology involved in acute renal failure (ARF). Include...
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