100 Cases in Clinical Medicine

CASE 42: POSTOPERATIVE DETERIORATION

History

The medical team is asked to review a postoperative surgical patient. A 62-year-old lady
had been admitted 10 days previously to have a right hemicolectomy performed for a cae-
cal carcinoma. This was discovered on colonoscopy which was performed to investigate an
iron-deficiency anaemia and change in bowel habit. She is otherwise fit with no significant
medical history. She is a retired teacher. She neither smokes nor drinks alcohol and is on
no medication. Her preoperative serum creatinine was 76&mol/L. The initial surgery was
uneventful, and she was given cefuroxime and metronidazole as routine antibiotic prophy-
laxis. However the patient developed a prolonged ileus associated with abdominal pain. On
postoperative day 5, the patient started to spike fevers up to 38.5°C and was commenced
on intravenous gentamicin 80 mg 8 hourly in addition to the other antibiotics. Over the
next 5 days the patient remained persistently febrile, with negative blood cultures. In the
last 24 h, she has also become relatively hypotensive with her systolic blood pressure being
about 95 mmHg despite intravenous colloids. Her urine output is now 15 mL/h.

Examination

She is unwell and sweating profusely. She is jaundiced. Her pulse rate is 110/min regular,
blood pressure 95/60 mmHg and jugular venous pressure is not raised. Her heart sounds
are normal. Her respiratory rate is 30/min. Her breath sounds are normal. Her abdomen is
tender with guarding over the right iliac fossa. Bowel sounds are absent.

Normal

Haemoglobin 8.2 g/dL 11.7–15.7 g/dL

Mean corpuscular volume (MCV) 83 fL 80–99 fL

White cell count 26.3% 109 /L 3.5–11.0% 109 /L

Platelets 94 % 109 /L 150–440% 109 /L

Sodium 126 mmol/L 135–145 mmol/L

Potassium 5.8 mmol/L 3.5–5.0 mmol/L

Bicarbonate 6 mmol/L 24–30 mmol/L

Urea 36.2 mmol/L 2.5–6.7 mmol/L

Creatinine 523 &mol/L 70–120&mol/L

Glucose 2.6 mmol/L 4.0–6.0 mmol/L

Albumin 31 g/L 35–50 g/L

Bilirubin 95 mmol/L 3–17 mmol/L

Alanine transaminase 63 IU/L 5–35 IU/L

Alkaline phosphatase 363 IU/L 30–300 IU/L

Trough gentamicin level 4.8 mg/mL !2.0 mg/mL

Urinalysis:'blood;'protein; granular casts and epithelial cells

INVESTIGATIONS

Questions

• What are the causes of this patient’s acute renal failure?


• How would you further investigate and manage this patient?