A 65-year-old patient 12 hours status post renal biopsy presents to the ICU with gross hematuria, acute blood loss anemia, and tachycardia. After two units of packed RBCs and DDAVP, with a normal INR and platelet counts, the patient continues to have significant gross hematuria with continued tachycardia and downtrending hemoglobin with a systolic blood pressure of 90 mm Hg.
What is the next BEST step?A. Surgical and Interventional radiology consultation
Correct Answer: A
It is important to recognize that bleeding is a primary complication of renal biopsy. Renal biopsy tends to have the highest bleeding risk compared to other biopsy sites with a rate of 1.2%. Bleeding after renal biopsy will most likely occur at three locations. One site of bleeding is into the collecting system, which can lead to microscopic or gross hematuria as seen in the patient above. The other two sites would be beneath the renal capsule presenting with pain post procedure or in the peri-nephric space in the retroperitoneum. The patient above has been given DDAVP and has a normal coagulation panel and a normal platelet count but continues to have gross hematuria with signs of shock. This patient should not be transported to the CT scanner as the patient is currently showing signs of shock. Although the CT angiography of the abdomen would be an ideal study to evaluate for active extravasation, this patient has gross hematuria with continued bleeding. Monitoring the patient and continuing transfusion is reasonable after the surgical service has evaluated the patient. In bleeding patients, it is reasonable to allow “permissive hypotension.” It is better to gently resuscitate than start vasopressors in a bleeding patient. The sudden rise in the mean arterial pressure and systolic blood pressures could lead to increased bleeding or reactivation of bleeding. The best decision for this patient is to get a surgical consultation and have interventional radiology on standby for angiogram, which can be both diagnostic and therapeutic in this patient while the patient is being monitored closely and transfused with appropriate transfusion ratios.