Essay 364

A healthy 39 year old woman has undergone laparotomy and myomectomy because of uterine fibroids. Her pre-operative Hb was 11.3 g/dl and the estimated blood loss was 700 ml. You are asked to see her because she has only passed 40 ml of urine over 4h post-operatively. (a) List the most important causes of oliguria in this woman [2 marks]. (b) Based on these causes, discuss your initial assessment [6 marks]. Two hours later, laboratory results show normal renal function and Hb of 6.8 g/dl and haematocrit of 0.24. Discuss your management [12 marks].

the two most important causes of oliguria in this woman are hypovolemia from acute blood loss and acute renal failure secondary to acute blood loss and decreased renal perfusion.

I should first check the medical file for this woman to look for the operative note, occurrence of any complications intraoperatively, length of surgery, any blood transfusion, and volumes already infused to the patient. I should also check the vital signs as low blood pressure, tachycardia > 100bpm, tachypnea >20breath per minute, orthostatic hypotension (drop in BP with upright position),  narrow pulse pressure (difference between systolic and diastolic pressure is decreased due to compensatory peripheral vasoconstriction secondary to hypovolemia). Pale conjunctiva denotes anemia, poor cappillary perfusion, weak thready pulse, and cold clammy extremities are detected with hypovolemia

Heart auscultation will reveal tachycardia and ejection systolic murmur due to hyperdynamic circulation secondary to anemia and hypolemia. Abdominal exam should look for abdominal distension and guarding with rebound tenderness as these are associated with intraabdominal bleeding. the dressing should be inspected for oozing. the colour and amount of fluid in the drain should be checked.

vaginal bleeding should be checked as this might reveal ongoing bleeding if excessive in amount.

lower limb examination should look for edema and tenderness over the calf muscles in order to detect DVT, as hypovolemia is associated with increased risk.

the management should be via multidisciplinary team, the anesthetist, the gynecology consultant, ITU specialist, blood bank and hematologist may be involved.

According the patient condition she should be cared for in ITU bed or in a HDU.

oxygen should be administered via a face mask to improve tissue oxygenation, two wide bore iv lines should be secured and crystalloids should be infused. central venous line can be inserted to guide fluid therapy.

blood transfusion should be performed after blood typing and cross matching and after obtaining an informed consent about blood transfusion and risks of blood transfusion namely fever, allergic or hemolytic reactions explained, and the benefits of transfusion to restore adequate tissue perfusion explained. the patient' s vital signs and oxygen saturation should be monitored during blood transfusion to detect pulmonary edema in case of volume overload.

TED stockings and Low molecular weight heparin should be considered and be given according to DVT risk assessment score, as the patient is at increased risk of DVT.

Accurate documentation of fluid balance and patient progress and debriefing of the patient should be done.

A)     The most likely cause of oliguria in this woman is normal physiological response following surgery. Other likely causes can be inappropriate fluid management in post operative period, intraperitoneal bleeding, injury to the ureter and injury to the bladder.

B)   Her clinical history with regard to the number of fibroids and location of fibroids should be noted. Operative notes should be viewed. Large size fibroids  in lateral uterine wall may displace the ureter making injury to ureter likely. Multiple uterine incisions, big size incisions and posterior wall incisions may lead to difficulty in approximation . Pulse rate, blood pressure, respiratory rate, temperature and general look of the patient should be assessed. Absence of tacycardia or hypotension may point towards normal physiological reason of oliguria. Per abdomen examination should be done to look for distension (due to intraperitoneal collection of blood or urine) . Skin incision should be examined for any muscle haematoma. Examination of genitals, bedsheet and  womans clothes to assess any urine leakage due to improper placement of foleys catheter. Her post operative charts for trend of vitals and fluid administered should be checked to determine adequacy of volume replacement.

C)      By the decrease in haemoglobin levels , a provisional diagnosis of intra peritoneal bleeding is made. Consultant on call as well as the operating consultant should be informed. I will assess first her airway, any difficulty in breathing and circulation status as low haemoglobin with ongoing bleeding can deterioate the womans condition very fast. Aim is to start resusitation, investigations and monitoring simultaneously to prevent development of hypoxaemia and end organ damage. Pulse oximetry should be connected and oxygen given via face mask at the rate of 10-15litre/min. Arrange for crossmatched blood . Crystalloid infusion , Hartman's solution uptil 2 litres, should be started for volume replacement till blood is arranged.  If further need arises colloid infusion can be given. Coagulation profile should be checked for development of DIC and component therapy given on advise of haematologist to maintain fibrinogen >1g/dl and platelet count >50,000/cumm. Ultrasound of whole abdomen is done to look for intraperitoneal collection of blood. If the womans condition is not improving in spite of resusitative measures, decision for re-exploration should be taken. Consent , after explaining the findings and emphasising the probability of hysterectomy, should be taken if the woman is in the state to understand otherwise doctrine of best interests of patient will apply. Surgery will be performed by a senior experienced gynaecologist in conjuction with a surgeon and skilled assisstant. Anaesthesia to be given by consultant anaesthetist. General anaesthesia will be preferable over regional because of the cardiovascular status of the woman, need of long surgery and better effect of resusitative measures in general anaesthesia. If bleeding point is localised after thorough lavage, it should be ligated. Persistent oozing from multiple sites may need the decision of hysterectomy necessary. Post operatively the patient should be managed in intensive care unit or High dependency unit. Thromboprophylaxis with LMWH should be given if there is no further risk of bleeding, otherwise TED stockings given .Thorough documentation is necessary. Adequate debriefing of the woman and the family members is necessary , preferably by the same consultant , at the earliest opputunity. A clinical incident reporting should be done for re-exploration and regular audits are required for the same.

A healthy 39 year old woman has undergone laparotomy and myomectomy because of uterine fibroids. Her pre-operative Hb was 11.3 g/dl and the estimated blood loss was 700 ml. You are asked to see her because she has only passed 40 ml of urine over 4h post-operatively. (a) List the most important causes of oliguria in this woman [2 marks]. (b) Based on these causes, discuss your initial assessment [6 marks]. Two hours later, laboratory results show normal renal function and Hb of 6.8 g/dl and haematocrit of 0.24. Discuss your management [12 marks].

A) 

1. Blocked urinary catheter.

2. Hypovolemia (due intra operative or post op haemorrhage) leading to anuria

3. Dehydration due to inadequate fluid management

4. Urinary tract injury

B) History is taken regarding abdominal pain, loin pain and adequacy of analgesia. Intra operative notes is reviewed to identify the difficulties  encountered during surgery like difficult dissection, hemorrhage. Information is obtained from the notes if the ureters have been identified during the surgery. Details of intravenous fluid management are noted.

Temparature, pulse and blood pressure are recorded. Pallor, restlessness, tachycardia, tachypnoea and hypotension suggest hypovolemia due to hemorrhage intraperitoneal or surgical haemotoma . Raised temparature, dry mucous membranes point towards dehydration. Drains are observed to detect the nature of draining fluid if blood stained or frank bleeding. Abdominal examination is performed to identify abdominal distension which is suggestive of intraperitoneal bleeding. Flank fullness and tenderness points towards urinoma due to ureteral injury. Suprapubic swelling and tenderness may be due to blocked urinary catheter not draining the bladder resulting in full bladder. Incision is examined to exclude haematoma or bloody discharge . Examination is undertaken to detect vaginal leaking of urine or bloody discharge.

C) Normal renal function excludes injury to the ureters. Reduced Hb and haematocrit suggest blood loss leading to hypovolemia.

Management should be undertaken in HDU by multidisciplinary team including senior Gynaecologist, Anaesthetist, Urologist and ITU physician.

Haemotologist should be contacted to discuss regarding the replacement of blood and blood products. If the woman's haemodynamic conditions is unstable, resuscitative measures should be carried out by providing facial Oxygen  , fluid replacement ( crystalloids and colloids) , and arranging blood transfusion. Monitoring is done by continuous recording of pulse, blood pressure, respiratory rate and SPO2. 

 Increasing abdominal distention , deteriorating haemodynamic status despite resuscitative measures, suggests continuous intraabdominal bleeding which prompts reoperation and exploration for the offending vessel. The woman and her family should be informed about the proceedings and requirement for the re- exploration and possible hysterectomy.. Consent is taken. Senior experienced surgeon's presence is essential to  perform the exploration and ligating the bleeding vessel.  Intra abdominal drains  are placed to identify further bleeding in the post operative period. A corrugated drain or a large bore drain secured with a purse-string suture from the vagina may be required  if hysterectomy is undertaken.

Radiologist's assistance is required to assist in  intraarterial embolization of the bleeding vessel. 

Post operative care should be continued in HDU as she is at risk of developing complications such as atelectasis, post operative ileum and coagulation abnormalities due to multiple blood transfusions.

 Appropriated thromboprophylaxis is provided once the woman is out of risk of further hemorrhage. 

debriefing is provided to the woman and her family members as soon as possible once her condition is stable.

Incident form is filled 

Essay 364

A)Most important causes of oliguria:

•                 Hypovolaemic shock seconday to post operative intra-abdominal bleeding.
•                 Inadequate fluid replacement. 
• .Acute renal failure
• urinary tract injury (bladder or ureter).

B)            Regarding initial assessment, review her operative notes. Note any intra-operative difficulties, operative procedure and any urinary tract injury. Review her fluid input/output chart to assess adequacy of intra-venous fluid therapy. Clinically, symptoms of dizziness, syncope, shoulder tip pain and nausea suggest intra abdominal haemorrhage. Flank pain radiating to the loin suggests ureteric injury. On examination note her general condition. Restlessness or stupor may be seen with major haemorrhage. Note her pulse, blood pressure, respiratory rate and temperature. Examine her mucous membranes. Pallour suggests anaemia secondary to haemorrhage. Sluggish capillary refill suggests hypovolaemia. Excessive diaphoresis and cold clammy extremities suggest hypovolaemic shock. On abdominal examination, distension, blood soaked dressings, generalized tenderness, rebound tenderness, guarding and loss of bowel sounds suggest intra-abdominal haemorrhage. Blood stained urine suggests urinary tract injury. Regarding initial investigations, include a complete blood count, renal function tests, prothrombin time and serum lactate. Low or falling haemoglobin levels suggest ongoing haemorrhage. Low platelet counts with prolonged prothrombin time suggest disseminated intravascular coagulation secondary to major haemorrhage. Elevated serum creatinine suggest acute renal failure or inadequate hydration. Elevated serum lactate suggests tissue hypoperfusion secondary to hypovolaemic shock.

C) Firstly, recognize that anaemia is likely due to major intra abdominal haemorrhage. Aims of management are to resuscitate, stabilize her condition and achieve haemostasis. Local protocols for management of post-operative haemorrhage should be followed. Adopt a multidisciplinary team approach. Inform the consultant gynaecologist, anaethesist, intensive care physician, haematologist nurse incharge of post-operative recovery and laboratory technicians. Commence oxygen therapy. Establish 2 large bore intra-venous accesses and commence a rapid infusion of warmed crystalloid solution. Adjust her position to lie flat. Take bloods for CBC, coagulation screen, serum lactate. Group and cross match 4 units of packed red cells, fresh frozen plasma and cryoprecipitate. Transfuse blood products when available and o negative blood in the interim. Monitor vital signs every 15 minutes. Arrange transfer to the high dependency unit. Regarding definitive management, ensure early recourse to exploratory laparotomy. Explain the examination findings and the possibility of hysterectomy. Document this discussion and obtain written consent. At laparotomy ensure meticulous haemostasis by oversewing visible areas of bleeding. Measures to halt uterine bleeding with uterine conservation include uterine artery embolisation, internal iliac or uterine artery ligation. However, early recourse to hysterectomy may be life saving. Where the patient remains stable, with no signs of hypovolaemic shock and the haemoglobin level is stable, expectant management is appropriate. Thromboprophylactic measures include graduated compression stockings. Consult the haematologist regarding use of heparin thromboprophylaxis. Unfractionated heparin is appropriate after haemostasis has been achieved in light of its shorter half life. It can also be reversed using protamine sulphate and monitored using the activated partial thromboplastin time. Fill an incident report form.

a) The most important causes here would be:

- Dehydration

- Acute Renal Failure

- Intraoperative ureteric injury

-Blocked indwelling urinary catheter

b) I will first assess her mental status -- whether she is drowsy or alert. I will look at her parameters, her temperature, blood pressure, pulse rate and oxygen saturations, which will inform me regarding her hydration status. I will  check her conjunctiva for any pallor and the mucosal membranes and skin turgidity for any dehydration.

At the same time, I will look through the intraoperative notes to get an idea as to whether there were any difficulties encountered during the surgery -- and adhesions, where the fibroid was, whether there was any difficulty in tracing the ureters post myomectomy. I will note if there has been any blood transfusion given intraoperatively, and how much fluid was replaced.

I will check her abdomen for any tenderness or distension -- which may point towards acute retention of urine or intraabdominal bleeding. The drain has to be inspected for drainage volume. The catheter will be cheked for any blockage of the lumen or kinking of the tube.

c) Firstly, I will fluid resuscitate the patient. I will fluid challenge her with crystalloids -- 500mls of normal saline in half and hour, followed by maintenance crystalloids, and further replacements guided by her clinical response. 

At the same time, blood will be take for group and crossmatch for at least 2 units of packed cells for transfusion. The platelet count and coagulation status have to be assessed, and platelet transfusion and fresh frozen plasma given as needed. 

I will continuously monitor her for any ongoing intraabdominal bleeding -- looking at the drainage volume and assessing the abdomen. 

I will speak to the anaesthetist and transfer her to the High Dependency Unit for intensive monitoring. Invasive monitoring such as central venous pressure may have to be instituted. I will watch closely her hourly urine output, and keep her on continuous monitoring of the vital signs, and put up a fluid balance chart. Maintenance fluids have to be given to prevent negative fluid balance. At the same time, her lungs have to be checked regularly to prevent fluid overload. I will also give her appropriate DVT prophylaxis -- Subcut Clexane 6 hours post operatively provided there are not other contraindications, graduated compression stockings and calf compressors while she is not ambulant yet. 

Her Hb will be rechecked 4 hours post transfusion, and transfused further as necessary. I will keep her Nil By Mouth in case a re-laparotomy is needed. 

I will inform my consultant of the events that have transpired and ask him for any other advice. I will also update the patient and her family. Fanilly, I will document clearly in the case notes about the events that have taken place.

The most likely cause would be hypovolemia due to either due to haemorrage or inadequate fluid replacement. Other cause could be inadvertent ureteric injury.

A look into the pre op records as the position of fibroids and the ot notes if the uterine cavity was opened ,or if the fibroids were intramural which would suugest haemorrage as a cause.History of vomiting in the immediate post op period would suggest hypovolaemia .A look int the intake chart as to what fluid has been given to look for appropriate perioperative fluid management.

Examination of the patient to look for pallor and other peripheral perfusion,pulse rate and B.P to be checked and recorded.(tachycardia p>90 ,hypotention,B.P<90/60)would be suggestive of hypovolemia.If b.p if very low ,pulse feebile consider JVP ,CVP monitoring .Abdominal examintion to look for any fullness,renal angle tendreness suggestive of ureteric injury .abdominal rigidity suggestive of haemorrage .Inspection of the pads to look for any excessive bleeding .The position of the catheter to be looked in for ,correct placement.

Investigations would include FBC, gp and crossmatch if clinically indicated  Coagulation profile if platelet count is less,Urea ,Creat and electrolytes.USS examination if patient is stable .

The surgeon  who operated  should be informed or the consultant gynecologist  ,the anaesthetist should be alerted .As there is a drop of hb ,it implies that she has bled more or there is  there is on going bleeding and patient needs immediate attention . The ot should also be alerted.The i.v channel to be assessed and if need be to start another line ,and start colloid  or crystaloids,till blood is availbe.Moniter the pulse ,B.P. output ,the oxygen saturation if <94 start oxygen .Consent to be checked and the need of hysterctomy discussed if not already discussed . If the patient does not settle  with the initial management,She would need laprotomy ,to secure haemostasis ,and removal of clots .(may even need hysterctomy) If there are facilities of uterine artery embolisation ,arrangements for the same to be made .

Post op she should be monitored in the HDU .with adequate bllod transfusion ,and monitoring.Thromboprophylaxis as per the protocol .Documentation of the proceduresto be done.

The patient should be debriefed when stable by the surgeon ,the sequences of the event and the need for them. . Discussion of the future implications and management to be planned in the post op reveiw.

Incident reporting form to be filled in.     

A)

the most important causes are hypovolemia due to intraoperative or postoperative blood loss and the deterioration fo the renal function. Bladder injury may contribute to the oliguria but would cause associated hematuria.

B)

The initial assessment should include review of the notes to see whether there were any difficulty in the procedure that may contribute to bleeding or urinary injury. Review of the MEWS score of the patient to see whther there are signs of hypovolemia like tachcardia, tachypnea, hypotension and  pallor. Besides, examination of the abdomen looking for signs of intraabdominal hemorrhage e.g. severe abdominal pains and guarding. If the patient has drains. I would look for the amount and recorded emptying of the drain. I would observe the urinary catheter to see if there is any blockage , or hematuria. I would review the fluid chart to see the fluid intake. I would then send for an urgent full blood count and Urea and electrolytes. If the patient is stable I would request an urgent ultrasound scan.

C)

According to the blood results , there is significant blood loss that does not match the recorded the estimated blood loss. I would send an urgent clotting test , and cross match 4 units of blood. I would make sure she has 2 large bore cannulas and the anaesthetic team and theatre staff are aware. I would inform the consultant responsible for the patient. If the patient is clinically stable, I would request an urgent Ultrasound scan. If the ultrasound shows intraperitoneal hemorrhage, I would inform the anaesthetist on-call and ask for the patient to be transferred to the theatre for the consultant to do an exploratory laparotomy after consenting the patient for the laparotomy plus repair of the damage withthe possiblity of a hysterectomy if there is a need to do so.

If the Ultrasound is normal, then blood transfusion should be considered if she is symptomatic because of the anaemia. Counselling the patient is important.

If the patient is not vitally stable then she needs to be stabilised before definitive management. Ultrasound cannot be awaited. Resuscitation include High flow oxygen, 2 large bore cannulas and start crystalloid and colloid fluid infusion until blood crossmatching is complete. Finally she needs to be transfered to the theatre for exploration and laparotomy.

If the patient is not well enough to consent for her self , the practice in the patient's best interest should be done after two physicians sign for the procedure.

a) Oliguria  in this lady may indicate renal hypoperfusion secondary to hypovolaemia resulting from intra-abdominal bleeding.  It could also indicate ureteric injury.

b)  The most crucial aspect of assessment would be to rule out acute haemodynamic compromise.  Observations including GCS would be performed before any further assessment and plotted on a MEWS chart.  BP would be checked to rule out hypotension and renal hypoperfusion, which if associated with tachycardia could indicate severe blood loss and decompenstaion.  This would indicate a medical emergency.  Temperature would also be cheked to rule out infection/sepsis and respiratory rate and O2 saturations would be taken to exclude respiratory complications.  If the patient is well enough to obtain a history I would enquire about  abdominal pain which may indicate intra-abdominal pathology, most significantly intra-abdominal bleeding.  Any  shoulder pain may indicate referred pain via the phrenic nerve resulting from peritoneal/diaphragmatic irritation.  Distention  with an otherwise unremarkable examination could also indicate urinary retention.  Flank pain/ back pain may indicate ureteric injury.  Palpitations (tachycardia) or symptoms of lightheadedness may point towards significant anaemia and therefore blood loss.   If the patient is still catheterised I would check the  catheter and flush to ensure it is not blocked.  I would check for any significant vaginal bleeding and note any losses which may point towards active bleeding.

c) The significant drop in Hb (11.3 to 6.8) and very low HCT point towards significant intra-abdominal bleeding.  This would require emergency resuscitation, stabilisation and ultimately transfer to theatre.  Immediate management would involve ensuring the lady has a patent airway and is breathing spontaneously with facial O2 given if SaO2 < 95% .  I would provide circulatory support via x2 large bore cannuale and proceed to fluid resuscitation.  If blood has already been cross matched I would obtain this and transfuse. Otherwise I would initially give up to x2 L of crystalloid whilst waiting for either the full cross matched blood or group specific blood.  If the patient is unstable I would give O negative blood.  I would call the consultant gynaecologist and inform of my concerns (i.e. need to return to theatre in view of intra abdominal bleeding) and I would contact the anaesthetic and theatre teams.  I would ensure the lady is catheterised.  If the lady is able to provide consent (i.e. she is not collapsed) I would gain consent for a return to theatre, laparotomy and control of haemorrhage which may require hysterectomy.  I would check platelet count and ensure a clotting profile has been taken to rule out the development of disseminated intravascular coagulation (DIC).  I would repeate biochemistry for  renal function and electrolytes  Additional blood products would be given after consultation with the haematologist if required.

a) Oliguria  in this lady may indicate renal hypoperfusion secondary to hypovolaemia resulting from intra-abdominal bleeding.  It could also indicate ureteric injury.

b)  The most crucial aspect of assessment would be to rule out acute haemodynamic compromise.  Observations including GCS would be performed before any further assessment and plotted on a MEWS chart.  BP would be checked to rule out hypotension and renal hypoperfusion, which if associated with tachycardia could indicate severe blood loss and decompenstaion.  This would indicate a medical emergency.  Temperature would also be cheked to rule out infection/sepsis and respiratory rate and O2 saturations would be taken to exclude respiratory complications.  If the patient is well enough to obtain a history I would enquire about  abdominal pain which may indicate intra-abdominal pathology, most significantly intra-abdominal bleeding.  Any  shoulder pain may indicate referred pain via the phrenic nerve resulting from peritoneal/diaphragmatic irritation.  Distention  with an otherwise unremarkable examination could also indicate urinary retention.  Flank pain/ back pain may indicate ureteric injury.  Palpitations (tachycardia) or symptoms of lightheadedness may point towards significant anaemia and therefore blood loss.   If the patient is still catheterised I would check the  catheter and flush to ensure it is not blocked.  I would check for any significant vaginal bleeding and note any losses which may point towards active bleeding.

c) The significant drop in Hb (11.3 to 6.8) and very low HCT point towards significant intra-abdominal bleeding.  This would require emergency resuscitation, stabilisation and ultimately transfer to theatre.  Immediate management would involve ensuring the lady has a patent airway and is breathing spontaneously with facial O2 given if SaO2 < 95% .  I would provide circulatory support via x2 large bore cannuale and proceed to fluid resuscitation.  If blood has already been cross matched I would obtain this and transfuse. Otherwise I would initially give up to x2 L of crystalloid whilst waiting for either the full cross matched blood or group specific blood.  If the patient is unstable I would give O negative blood.  I would call the consultant gynaecologist and inform of my concerns (i.e. need to return to theatre in view of intra abdominal bleeding) and I would contact the anaesthetic and theatre teams.  I would ensure the lady is catheterised.  If the lady is able to provide consent (i.e. she is not collapsed) I would gain consent for a return to theatre, laparotomy and control of haemorrhage which may require hysterectomy.  I would check platelet count and ensure a clotting profile has been taken to rule out the development of disseminated intravascular coagulation (DIC).  I would repeate biochemistry for  renal function and electrolytes  Additional blood products would be given after consultation with the haematologist if required.

An incident form would also need to be filled

a) The most important causes of oliguria in this woman are transient physiological response following prolonged surgery and also may be due to excessive ureter handling. Blocked urinary catheter due to blood clot, dehydration, inappropriate fluid management and renal dysfunction following acute blood loss due to intra-peritoneal bleeding and hypovoluemia are other common causes of oliguria following surgery. Ureteric injury is very important cause of oliguria following myomectomy. Difficult dissection, broad ligament, cervical fibroids may deviate the normal ureteric path and make it liable to injury in form of crushing, angulation, ligation and transection.

b) Our initial assessment should include thorough examination of the patient. Examine hydration, pulse, blood pressure, chest and CVS, temperature of extremities for signs of dehydration, shock and hypovoluemia .Examine if urinary indwelling catheter is not misplaced and blocked due to some blood clot; so flush it with 20 ml normal saline or just change it. See records if proper fluid is administered following surgery. Assess for post-operatively transient loss of renal function by  intravenous injection of 20 mg frusemide. Examine the wound site for any hematoma, abdominal drain for any fresh blood collection which may indicate intra-abdominal bleeding. Abdominal guarding suggests intraperitoneal bleeding, flank tenderness and fullness suggests urinoma formation due to ureteric injury. Per speculum examination to see for vaginal bleeding is not excessive. See the operative notes for difficulty of procedure and location of fibroids which may provide a clue, if ureteric injury is suspected.

c) Lab results suggestive of normal renal function likely excludes any ureteric injury. Hb of 6.8 g/dl and hematocrit of 0.24 is strongly in favour of intrabdominal bleeding, acute blood loss and decreased renal perfusion resulting in oliguria. Resuscitative measures should be started to stabilise her condition. High flow oxygen @3-5L/min after confirming the patency of airway. Group and cross matching should be done, appropriate units of blood should be arranged .Infuse crystalloids or colloids if required to maintain her hemodynamic instability till blood is arranged.USG whole abdomen must be performed to see for intra-peritoneal collection. Still after all conservative measures, her hemodynamic status deteriorates, with high risk consent, patient has to be taken up for Re-exploratory laparotomy. High risk consent has to be taken for hysterectomy, multiple blood transfusions, multiple organ failure as hazard of hypovoluemia, renal failure and loss of life.

Pre-operative coagulation profile, D-dimer tests must be performed to rule out if patient is not in DIVC. Multidisciplinary approach is required involving senior anaesthetist, haematologist, general surgeon, senior gynaecologist and interventional radiologist during exploratory laparotomy. During laparotomy see if any slippage of ligature is there or if any bleeder is left from coagulation and manage the condition accordingly. Check if there is not any oozing from the myoma bed and obliterate the dead space of myoma bed properly .If no bleeder is found, and there is generalized oozing, may require total hysterectomy followed by uterine artery embolisation, bilateral  iliac artery ligation . Thorough suction , irrigation and lavage must be done as accumulated blood in the peritoneal cavity may cause peritonitis. Appropriate haemostasis must be achieved before closing the abdomen.

Post-operatively patient must be managed in ICU with 1:1 nurse: patient ratio. Strict monitoring of vitals, input/output charting, blood/packed RBCs transfusion and fluid & electrolyte balance must be carried out. DVT pumps/TED stockings, two hourly spirometry are must in post-operative management. Appropriate thrombo-prophylaxis must be offered with LMWH, on POD-2/3 when there is no active bleeding; as these patients are highly susceptible to DVT due to prolonged surgery and multiple transfusions.

Incident chart must be filled

A)

The 2 most important causes of oliguria are

1)intraabdominal bleeding from the uterus

2) ureteric injury

b)

My initial assessment would be as follows. I would take further history from the patient: any symptoms of anemia such as giddiness or breathlessness, any abdominal or wound or catheter site pain, abdominal distension, vaginal bleeding, bleeding from the abdominal wound; any medical conditions such as renal disease. I would review her operation notes regarding difficulties in surgery, any intraoperation blood transfusion. I would review her postoperative management regarding her postoperative fluid replacement regime, any postoperative investigations or pad charts for amount of vaginal bleeding. I would examine the patient for her blood pressure, pulse rate, respiratory rate, oxygen saturation, conscious level, any pallor, abdominal examination for tenderness, palpable bladder or distension or shifting dullness for free fluid. I would examine her operation wound for bleeding, any heavy vaginal bleeding , if urinary catheter is blocked and I will check the urine bag for any bloodstained urine. I would send off blood tests for full blood count, renal panel and group crossmatch. I would consider performing an ultrasound of her abdomen to look for free fluid.

c) I would assess her airway, breathing and circulation. I would set 2 large bore IV cannulas, take bloods for group cross match if not already done so and a coagulation panel. I would monitor the patient’s vital parameters such as blood pressure and pulse rate continuously as well as input/output charting, this would be charted on a modified early obstetric warding system chart. If the patient is unstable, I would consider transferring her to the high dependency or intensive care unit. I would call for assistance from my nurse and inform my consultant as well as the operating surgeon. I would transfuse the patient with at least 2-3 units of whole blood or packed cells. I would recheck her full blood count 4 hours after transfusion. While awaiting the blood for transfusion, I would give her IV crystalloids or colloids if needed. I would also consider invasive monitoring such as central venous pressure lines if patient is unstable and multidisciplinary support from anesthetetists and intensivists. If I suspect intraabdominal bleeding as the cause of her severe anemia, I would consider further investigations with ultrasound of her abdomen or CT abdomen/pelvis, however if patient is unstable and intraabdominal bleeding is suspected, I would consider an exploratory laparotomy. I would communicate patient’s progress and management to her and her family. Once patient is stabilised I would debrief her and her family and perform incident reporting if source of her bleeding was an intraabominal bleed.

A)
Inadequate fluid replacement intra-operatively and post operation
Injury to ureter or bladder
Blocked urinary catheter
Current intra-abdominal bleeding

B)
Determining whether the patient is oriented and not confused and asking about symptoms of anaemia ( dizziness, palpitations, headache) and dehydration is important in the initial assessment however this may be difficult to interpret as the patient had general anaesthetic.
I would initially perform an examination which would entail proper measurement of blood pressure (BP), pulse, capillary refill time and and quality mucous membranes (mm) as hypotension and tachycardia are signs of hypovolaemic shock while increased capillary refill and pale and dry mm indicate signs of dehydration.
Abdominal examination measuring abdominal girth and evaluating whether there is oozing of blood from the surgical site is also important as this may indicate signs of intra-abdominal bleeding.
Examination of the catheter site looking for signs of blockage is also important.
After my examination, I would carry out a full blood count (FBC) and renal function tests (RFT) in order to determine if patient is anaemic and presence of features of acute renal  failure. I would also request a portable abdominal and pelvic ultrasound scan to determine the amount of free fluid in the abdomen

C)
I would first call for help from the senior gynaecologist on duty, consutant anaesthetist, hematologist, senior nurse with early involvement of laboratory staff as this patient will also need blood products.
This patient requires initial resuscitation with intravenous crystalloids (2 litres) and colloid (1.5 litres). This patient should be on oxygen 10 to 15 litres via facemask. While this is in progress, I would ensure the patient receives continuous monitoring of BP, pulse and Electrocardiogram as this patient is also at an increased risk of an arrhythmia. Blood should be drawn for FBC, RFT, clotting factors and group and crossmatch for 6 units of packed cells with 4 units of fresh frozen plasma(FFP).
This patient will need exploratory laparotomy to determine the cause of the drop in Hb. The decision for laparotomy should be made by the consultant gynaecologist with involvement of haematologist and anaesthetist. The patient must be consented as to the risks of blood transfusions, intra-operative damage to pelvic structures like bladder, ureters and bowel.
Risk of disseminated intravascular coagulation, possible need for hysterectomy with ovarian conservation and death should also be discussed.
This patient may need care in the intensive care unit with central venous pressure monitoring intra-operatively and postoperatively and should be informed of same.
The sequence of events during the resuscitation needs to be recorded by an appointed scribe with documentation of time of arrival of necessary staff, arrival of blood products requested, timing of interventions and timing of decision for surgery

a) The most important causes of oliguria in this patient are: prerenal- intraperitoneal bleed, dehydration (fever, insufficient post op fluids), post renal-ureteric and bladder injury, blocked or misplaced cathetre.

b) Tachycardia, hypotension and pallor would indicate blood loss. Raised temperature, respiratory rate and dry skin and tongue and a concentrated urine would indicate dehydration. hematuria will be present in renal tract injury. I will also check the position of cathetre and flush it if its in correct place. Abdomen should be examined for the signs of acute abdomen, though this will be difficult to elicit as patient will be in post op pain. Checking of operativ enotes is important for any difficulty in surgery or intraop visceral injury and level of haemostasis. Preliminary investigations like FBC for anemia, U&E for renal function and coagulation screen for DIC will be sent.

c) The most likely diagnosis is intraperitoneal bleeding and management would involve monitoring of pulse, BP, respiratory rate and sats every 15 min and temperature every hour. cathetre would be connected to urometer. After inserting 2 large bore IV cannulae, blood is sent for crossmating 6 units of blood. Consultant gynaecologist, anaesthetist and haematologist are informed. Theatre staff alerted for laparotomy. Blood bank informed for the availability of blood products like FFP and cryoprecipitates. HDU/ITU informed for the availabilty of bed. In the meanwhile resuccitation is done with iv crystalloids and colloids, oxygen by mask. Probable diagnosis and further management discussed with the patient, an urgent bed side

abdominal ultrasound and or departmental CT arranged. Patient is stablised with fluids, blood and blood products prior to laparotomy. All the events with timeline are documented, patient debriefed and an incident reporting done and appropriate thromboprophylaxis given postoperatively.

abdominal ultrasound and or departmental CT arranged. Patient is stablised with fluids, blood and blood products prior to laparotomy. All the events with timeline are documented, patient debriefed and an incident reporting done and appropriate thromboprophylaxis given postoperatively.

  A The important cause of oliguria might be  1 Post operative bloodloss ,2 Accidental damage to the ureter      B

   B  i will asses the general condition of the patient and a quick revive of her vital chart for her temperature,pulse ,bp ,and input and out put chart .I would like to know the amount of fluids given to her was adequate or not, check for the signs of dehydration like her tonque,skin turgour,if the patient is consious and alert, check for signs of hypovolumia like is she having tachycardia, theardy pulse, hypotension,. if she is going into shock by felling for her extremities if cold .check for anemia for signs of pallor in eyes and tongue  Palpate her abdomen for any tenderness, abdominal distention, any gaurdinf and rebound tenderness,check the dressing of her wound if soaked, and check the abdominal drain,its colur and amount. i will request for her blood to be sent for following quick investigations like hb level,group and cross match,renal function test, blood gas analysis at bed site, coagulation profile,i would rewive her post operative notes to check if the fibroid was extendging in the broad ligament by which the ureter would have been damaged . if the patient is unstable i will transfer her to HDU and request the anaesthetist for a central venous line .     C Once the resuts are available the possible cause could be post operative haemarrage the patient should have two large bore iv line,she must be given crystalloid,the condition must be explained to the patient sensitIvely and inform her that she might need explorative laparotomy and taken consent , multidisciplinary team like anaesthesist,haematologist,urologist is informed ,we should enter the theatre with 4 units of blood ,in the consent inform the patient that she might end up with hysterectomy ,  this issue must be handeled very skillfully and empathetically with her and her partner or relatives , in the theatre she might had total abdominal hysterectomy , or repair of the  damaged ureter, if the ureter is kinking it is released,    After the laporatomy the patient is transfered in HDU and monitored for 24 to 72 hrs,  the patient is given high spectrum antibiotics,low molecular weight heparin for 5 days or ted stocking, early ambulation,      Before discharge post operative date for followup, she might need psychiatric councelling for the mental trauma she underwent, numder of support group and written information .                                                                                                                   

Dear Mr Paul,

Please could you correct my essay. The last corrected one is just short of mine and I have been  eagerly opening my hoping to see what my flaws are, please correct it.

Thanking You

Sujata Bhat

Dear Mr Paul,

Please could you correct my essay. The last corrected one is just short of mine and I have been  eagerly opening my hoping to see what my flaws are, please correct it.

Thanking You

Sujata Bhat

a) the most important causes of oliguria in this woman are hypotentension leading to decreased renal perfusion . this may be due to inadequte fluid replacement intra- and post-operatively. She may have persistent intra-abdominal bleeding due to inadequate haemostasis. acute renal failure may be precitated by hypovolaemia or anaesthetic drugs. The catheter may be kinked causing obstruction to the outflow of urine

b)I will check the fluid chart in her notes to ensure she received adequate fluid replacement. I will also check the operation notes to see if any difficulty in achieving haemostasis was recorded. The catheter will be checked to see ensure it is correctly placed and not kinked.

The trend in vital signs will be assessed. Rising pulse rate and falling blood pressure may indicate continuing blood loss.

a) the most important causes of oliguria in this woman are hypotentension leading to decreased renal perfusion . this may be due to inadequte fluid replacement intra- and post-operatively. She may have persistent intra-abdominal bleeding due to inadequate haemostasis. acute renal failure may be precitated by hypovolaemia or anaesthetic drugs. The catheter may be kinked causing obstruction to the outflow of urine

b)I will check the fluid chart in her notes to ensure she received adequate fluid replacement. I will also check the operation notes to see if any difficulty in achieving haemostasis was recorded. The catheter will be checked to see ensure it is correctly placed and not kinked.

The trend in vital signs will be assessed. Rising pulse rate and falling blood pressure may indicate continuing blood loss.

Dear mr paul , can you please go through my answer to essay no 364                                                                            Thanks

Dear Paul,

I would just like to clarify a couple of points on essay technique which appear to have become apparent following essay 364.  In question 364 I have been awarded zero marks for part a, despite providing the two most likely causes of oliguria along with an explanation (the question stem was worth 2 marks so the 2 most likely causes given with explanation)

I appreciate the 1st part of the question states "list" and I didn't specifically list, however, on the College exam guidance its states that we must NOT list anything otherwise it will not be marked.  Indeed, I have been informed by several College examiners that lists/bullets/points will be crossed and scored ZERO, and this has again been confirmed on a recent Part II course (are all these people worng and does the College contradict itself?).  Further, I have been advised that any point documented needs to be clarified with an explanation i.e. renal hypoperfusion secondary to hypovolaemia from blood loss instead of just' blood loss'.    

I am extremely grateful for your marking and guidance (along with an absolutely excellent website!), but I am now just a little confused as how best to focus my essay writing.  Again I have been advised  that a succinct introduction, even though worth no marks is invaluable and sets one apart from Joe Public who will cover exactly the same points as I do.  The examiner apparently needs to differentiate between a 10/20 candidate (borderline) vs the 16/20 excellent candidate....is this correct?  Not having sat the exam before I am uncertain who or what is right.

I would be so very grateful for some feedback.

With grateful thanks

Christa