HYPOVOLEMIA CASE

Hypovolemia Case

Hypovolemia Case

Total hip replacement has become an acceptable method of treating severe arthritis of the knee. The operative procedure must be performed with precise skill and accuracy. Meticulous alignment of the prosthetic components can reduce many of the complications. Fine attention to general operating technique with adroit handling of tissues and efficient teamwork can reduce operating time to a minimum and thus avoid exposing the wound for an inordinate amount of time. An experienced, efficient technique also aids in preventing deep venous thrombosis and unnecessary scarring and decreases many of the complications that are associated with total knee arthroplasty. (Ulrich 2010 341-347)

Hypovolemia

Hypovolemia basically means low blood volume. "Hypo" means low, "vol" is for volume, and "emia" refers to blood. Symptoms of hypovolemia may include cold hands and feet, light headedness, infrequent urination, increased heart rate, and weakness.

History

A 66-year-old female presented with bilateral groin and lateral thigh pain of 4 years' duration. Her symptoms, initially worse on the right side, had progressed to the point that she became housebound. She had a bilateral total hip replacement and bled over 1000mls she received 12units of blood post operatively. She had tried multiple nonsteroidal antiinflammatory drugs and was currently taking meloxicam (Mobic) with only partial relief of her pain. Based on a recent MRI scan, she had been presumptively diagnosed with osteonecrosis involving both femoral heads and was referred for treatment. On examination, the patient was in no acute distress. She ambulated with a slightly antalgic gait on the left. Her left hip incision was well healed and nontender. (Torre 1987 187) The left hip had full range of motion, with reproduction of her groin pain at the limits of motion. Neurovascular examination of the left lower extremity was unremarkable. Her left THR was complicated by a late-onset coagulase-negative Staphylococcus infection which was treated by 2-stage exchange arthroplasty. She then did well until approximately 6 months prior to the current visit, when she developed new onset of left groin and proximal thigh pain, present with every step. She denied any fevers, chills, or weight loss and had not noticed any erythema or drainage at the surgical wound site.

A renal biopsy showed acute tubular necrosis of the cadaveric kidney. The patient required dialysis for three weeks postoperatively, during which time the output of urine returned to normal. He was then discharged home with baseline levels of blood urea nitrogen of sixty-three milligrams per deciliter (22.5 millimoles per liter) and creatinine of 5.7 milligrams per deciliter (504 micromoles per liter). Over the subsequent months, the patient continued to do well. He had improved function of the kidney, and the creatinine level returned to the preoperative level of 1.6 milligrams per deciliter (141 micromoles per liter). At the time of the most recent follow-up, the patient had returned to work at full capacity, the transplanted kidney continued to function well, and no additional renal treatment had been necessary. (Rosenberg 2007 82-5)

Physical Examination

At her initial presentation, she was a very pleasant, non-obese woman in ...