The patient continues to have persistent blood drainage from his abdominal drain overnight. He stops making urine for last 6 hours, which was not identified until morning. In the morning, his vitals are:
He has the following lab values:
You transfuse him 3 units of packed red blood cells and 1 unit of fresh frozen plasma and notify the surgeon of the bleeding. He is taken to the operating room where his surgical bleeding is identified and repaired. He receives 2 L of crystalloid, 2 unit fresh frozen plasma, and 2 units of platelets in the operating room, but his urine output does not improve. In the next 12 hours, his vitals are normalized but he remains anuric.
Which of the following is most likely to prevent the need for dialysis?
A. MannitolCorrect Answer: D
Based on the information provided, this patient’s acute kidney injury has likely progressed to acute tubular necrosis (ATN). Treatment of ATN is generally supportive and involves establishing and maintaining adequate renal blood flow and mean arterial pressure to prevent further ischemia and injury while the kidney recovers. Dialysis can be used to address complications of renal failure such as fluid overload, hyperkalemia, signs of uremia, or severe metabolic acidosis. Diuretics (Answers A and B) are often used to manage volume overload in patients with nonoliguric ATN and hypervolemia who are responsive to diuretics. It has not been shown to promote renal recovery but can be useful in volume management. When infused in low doses, (0.5-3 µg/kg/min), dopamine dilates the interlobular arteries and both the afferent and efferent arterioles. The net effect is a relatively large increase in renal blood flow with a lesser or no elevation in glomerular filtration rate. Despite this effect on renal vasculature, dopamine at “renal doses” has not been shown to improve mortality, prevent the progression of prerenal disease to ATN, or prevent the need for dialysis (Answer C).
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