Case Presentation

Dana Assis 10/13/2015

• CC: altered mental status • HPI: 68yr AAM hx of bladder cancer s/p

cystectoprostatectomy 2013 w/neobladder formation, CKD (baseline Cr 2-3 2/2 multiple admits AKI), brought in by family AMS.

• ROS: positive abdominal pain, decreased urinary drainage. Denies F/C/N/V/D

• All: NKMA • Home Medications

– Omeprazole 20mg daily – Sildenafil 100mg tab – Acetaminophen 500mg tab – Gabapentin 300mg cap – Aspirin 81mg – Amlodipine 5mg tab

• PMHx: CVA no residual impairment, Psoriasis, HTN, Bladder Cancer, OSA

• PSHx: Bladder cancer s/p cystoprostatectomy with neobladder creation

• Social denies toxic habits

• Admit 2/2015: Pw decreased urine output, abd pain, nausea, vomiting, and fevers for 2days. Inpt meds: ceftriaxone, bicitra. At this time foley catheter, neobladder irrigated, discharged home with foley. Ucx with Klebsiella and streptococcus.

Admit Date

Na K Cl CO2 BUN Cr Ca GFR AG

11/2014

139 4.3 119 17 97 2.7 8.7 30 3

2/17/15 138 4.2 115 14 54 2.3 8.8 37 9

2/25/15 135 4.8 114 10 73 2.9 8.7 28 11

2/27/15 139 4 115 15 54 2.2 8.6 39 9

• Admit 4/2015: pw abdominal pain found to have neobladder perforation. Had ex lap with repair of neobladder placement of suprapubic catheter 22ft foley 22ft suprapubic tube #10 jackson pratt drain in pelvis. Was not discharged on bicitra. amlodipine 10mg daily, hctz 25mg daily, lisinopril 10mg daily,

• Admit 6/15: abd pain and constipation suprapubic catheter in place 3L drained on admission.

Admit Date

Na K Cl CO2 BUN Cr Ca GFR AG

4/18/15

140 4.8 114 13 59 4 8.7 19 13

4/19/15

144 4 120 15 53 3 7 27 9

4/23/15

141 3.6 114 22 23 1.4 7.6 65 5

6/5/15 139 4.7 111 13 64 2.8 8.7 29 15

6/7/15 134 - 113 10 54 2.6 9 32 11

6/8/15 146 4.7 124 14 47 2.4 8.9 35 8

PE: BP 121/59 P 77 T 98.6 R 19 Gen: NAD, alert, awake, oriented x3 HEENT: MMM JVP not elevated CV: RRR no MRG PULM: CTA BL ABD: BS positive, soft, ttp LLQ, ND, left abdominal urinary catheter GU: urethral foley in place CYU Ext: no edema

pH 6.9

pO2 27

pCO2

37

Base excess

-22

Na 134

K 6.7

Cl 120

CO2 7

Bun 95

Cr 4.8

Glc 131

Date Sp gravity

pH Protein Wbc Rbc

8/17/15 1.012 9 500 13 15

Date pH pCO2 pO2 HCO3 Lactate 8/18 12am

7.170 23 136 8 1.3

8/18 5am

7.190 24 122 8.9 0.8

Date Na K Cl CO2 BUN Cr Ca GFR AG 8/18/15

139 5.1 122 9 96 4.7 9.2 16 8

8/18 4pm

141 5.2 120 9 94 4.1 8.9 19

8/19 7am

145 3.6 117 16 76 3.7 8.2 21 12

8/19 6pm

141 3.6 115 16 65 2.8 8 29 10

• Imaging: CT AP NC • No evidence of hydronephrosis. air is seen within the right

collecting system. patient is status post remote cystectomy with neobladder creation. neobladder is collapsed and cannot be adequately assessed. air is seen within urinary bladder. again noted is suprapubic catheter, presumably within neobladder although difficult to assess in setting of bladder collapse. interval placement of foley catheter. multiple surgical clips in pelvis.

• 6/17/2015 bilateral moderate hydronephrosis and hydroureter with prominent fluid distension of urinary bladder. no definite ureteral calculi.

• Hyperchloremic non anion gap metabolic acidosis

• Respiratory compensation • Obstruction / AKI • ?Infectious etiology • ?Type 4 RTA (CKD)

Urinary Diversion

• Managing Patients – Metabolic Acidosis – Stone Formation – Bone demineralization

Non continent urinary diversion

Continent Urinary Diversion – Orthotopic Neobladder

Contraindications

Bone demineralization

Questions