![Room9er ["Room Niner"]:](https://room9er.com/wp-content/uploads/2020/03/cropped-Screen-Shot-2020-03-08-at-3.16.16-PM.png)
This is a case that ended up being a 72 hour return. Another good example that sinus tach should have a good explanation. Another good reason to know discharge vitals!
Middle aged M, history of TBI, PE, MRSA bacteremia, s/p trach/g-tube/IVC filter, presents with displaced g-tube and increased agitation. Trauma consulted, g-tube replaced. Fluro shows good placement. Exam otherwise unremarkable. No labs performed. Documentation of to be non-verbal/not following commands and this was baseline. VS prior to discharge. Normal BP, HR trend: 68->70->115->111 (at discharge)
Patient returns for changed mental status. Not documented in what way he was changed from baseline. But found to have BUN: 115., Cr: 2.96. BP 90’s systolic, HR wnl. Head CT negative. Hgb: 12, INR: 1.6 (on coumadin) Na: 154, Cl: 112. Otherwise labwork unremarkable.
Patient admitted to medicine service. Hgb trended down 12.4->9.8->8.4. Patient receiving IV fluids during this time. Mild improvements in BUN/Cr. Patient was a STAT response 5 days later. Hypotensive/tachy. Hgb: 5.3 Dark stools noted. Transferred to MICU. GI scoped, found to have erosion of IVC filter into duodenum. Vascular consulted. Patient transfused/stabilized. IVC filter removed, transferred to floor. BUN/Cr normalized during stay.
Two things here, the HR as mentioned, should always have a good explanation. In a patient like this, the history is limited, more information is probably useful than less. Granted a patient like this is very difficult to evaluate at baseline, I’d lean towards shotgun labs/imaging etc. Not sure if it would’ve made a difference in the end but nonetheless.
On the 2nd visit though, a BUN of 115 should raise an eyebrow That’s a BUN/Cr ratio greater than 20. This patient could be just a simple AKI due to hypovolumia. But a BUN that high should also raise the suspicion of a GI bleed. A hemoccult probably is indicated at this point (for somebody that can’t relay much information at baseline). I don’t think anybody would’ve predicted the cause, but nonetheless, neither any of us, nor IM really interpreted that BUN as it should’ve. Just a few notes on Bun/Cr below taken from life in the fast lane. Not definitive, but just something to do a double take on.
Urea:Creatinine Ratio (in the setting of renal failure / elevated creatinine)
20:1 – normal or post renal cause of AKI
>20:1 – pre-renal cause (urea absorption increased compared to creatinine)
<20:1 – intrinsic renal damage (urea unable to be absorbed -> become like creatinine -> ratio gets closer to 1)
Yes good case. These are always tough patients. Have to lean on the nursing home staff to get information about baseline, about changes.
The BUN 115, Cr 2.96 IS a GI bleed until proven otherwise. The ratios you list at the end seem high to me. I always learned >20:1 prerenal, less than than post or intrinsic. Anyone 30:1 or greater should raise suspicion for prerenal, and anything 40:1 is likely a GI bleed. Exogenous steroids are another cause of increased ratio.
Another question in this case is what were the goals of care for this patient. Looks like quite of few interventions for someone who does not communicate much at baseline. Sometime this stuff snowballs.
This is why I will be somewhat agressive early on in these patients. Especially if DNR. Acting quickly to treat progressive conditions like a GI bleed can save a lot of money and interventions the patient may not want. DNR can mean be expedient on noninvasive measures to make sure you don’t reach a critical situation.
Yea you’re right Martin. I copied and pasted them and honestly the way it’s worded from the site was just odd. But the numbers I’ve learned and easy to remember center around 20