Radical Nephrectomy with Inferior Vena Cava (IVC) Thrombectomy: Implications for Post-operative Nursing Care

Implications for Post-operative Nursing Care

Janee Klipfel, BSN, RN, CURN; Therese M. Jacobson, MSN, APRN-BC, CWOCN; Michelle Havel, BSN, RN, CURN

Disclosures

Urol Nurs. 2010;30(6):347-352. 

In This Article

Post-operative Complications – Implications for Nursing Practice

Critical thinking is necessary for the early recognition and treatment of post-operative complications. Nurses need to understand the surgical procedure, its inherent risks, and knowledge of a patient's co-morbidities to anticipate potential problems, perform focused assessments, and proactively manage the patient's care.

The presence of an inferior vena cava tumor thrombus in renal cell carcinoma adds complexity to the surgical procedure and the potential for complications. Early reported complications include but are not limited to death, hemorrhage, pulmonary embolism, deep vein thrombosis, myocardial infarction, wound infection, sepsis, reoperation, ileus, and acute renal failure (Blute et al., 2004; Boorjian et al., 2007). Knowledge of the common signs and symptoms of post-operative complications is critical to timely identification by nurses (see Table 1). It is also important to be aware that as the level of the tumor thrombus rises, there is a significantly higher rate (p < 0.001) of early post-operative complications (Blute et al., 2004). In their case series of 659 patients, Boorjian et al. (2007) reported 46.9% of the 32 patients with a Level IV thrombus and 25.7% of the 35 patients with a Level III thrombus experienced some type of early complication.

For all patients, ileus was the most frequently reported early complication followed by hemorrhage (Boorjian et al., 2007). To detect hemorrhage early, nurses monitor heart rate, blood pressure, urine output, and hemoglobin, and note if the patient reports of dizziness or pain. If bleeding occurs in the retroperitoneum, the potential for lumbar nerve compression by a hematoma exists. Lumbar nerve compression symptoms include pain, sciatica, tingling sensations, sensation of pins and needles, and weakness or numbness in the buttocks, legs, or calves (Eidelson, 2009).

Early recognition and treatment of sepsis is paramount to good outcomes. A patient with sepsis requires immediate administration of appropriate antibiotics and fluid resuscitation in sufficient volumes to keep mean arterial pressure equal to or above 65 mmHg (Mayo Clinic, 2008). If a patient's condition begins to deteriorate, the rapid response team is activated. A standardized communication technique that includes a description of the Situation, Background information, Assessment, and Recommendations (SBAR) is used. Severe sepsis is associated with dysfunction of one or more organs. Measures of dysfunction of the various body systems include, but are not limited to, a systolic pressure less than 90 or a more than 40-point drop from baseline for the cardiovascular system, a Glasgow coma scale score less than 15 for the central nervous system, a platelet count less than 100,000/mL for hematology, bilirubin greater than 2.0 mg/dL for the hepatic system, and creatinine greater than 2.0 mg/dL. An elevated serum lactate indicates that an organ is not being perfused adequately (Mayo Clinic, 2008).

If a vascular bypass procedure is necessary, nurses must understand the inherent risks. In general, a vascular bypass is necessary more often when the thrombus is partially rather than completely occluding the IVC. When such a procedure is necessary, operative and anesthesia times as well as blood loss can increase. Blute et al. (2004) reported that venovenous bypass required significantly less time for anesthesia and surgery (p = 0.002) than the cardiopulmonary bypass with circulatory arrest. It is recognized that each type of bypass procedure carries its own risks.

Coagulopathy and neurologic complications are possible when cardiopulmonary bypass is required (Wotkowicz, Wszolek, & Libertino, 2008). The anticoagulation necessary during cardiopulmonary bypass is not required for veno-venous bypass; therefore, coagulopathies are less likely to occur (Blute et al., 2004). When a veno-venous bypass is used, there is the potential for a hepatic venous hemorrhage (Wotkowicz et al., 2008). When a bypass procedure is necessary, the patient is generally monitored in the cardiac intensive care unit for one to two days. Implications for nursing practice following bypass procedures include close monitoring of platelets, complete blood count, creatinine, blood urea nitrogen, urine output, and neurologic status.

When the surgical procedure involves reconstruction of the vena cava or ligation, patients require long-term anticoagulation therapy with warfarin (Blute et al., 2007; Boorjian et al., 2007). Nursing responsibilities include monitoring for bleeding and aPTT levels while the patient is receiving heparin infusion during hospitalization. A 30% to 50% decrease in platelet count may signal the onset of heparininduced thrombocytopenia (UAB Coagulation Service, n.d.). As the patient transitions from heparin to warfarin, aPTT levels are monitored concurrently with INR levels until the INR is within the specified therapeutic range. In addition to a bleeding disorder, coagulopathy may also be a clotting problem. Graduated compression stockings and sequential compression devices are initiated just before surgery and continued post-operatively for thromboprophylaxis (Geerts et al., 2008).

Acute renal failure may occur following a nephrectomy. Appropriate renal status assessment includes closely monitoring urine output, serum creatinine, blood urea nitrogen, daily weights, and peripheral edema. It is also important to be aware of medications that may be nephrotoxic and contraindicated when renal insufficiency occurs.

Knowledge of the anatomic location of the kidneys in relation to other organs provides insight into other possible complications, such as pneumothorax, injury to the bowel or spleen, and pancreatitis. Pneumothorax is generally treated with insertion of a chest tube and daily chest X-rays to monitor status. If pancreatitis is suspected, amylase and lipase levels will be monitored while the patient receives parenteral nutrition. If bleeding is severe following a splenic injury, a splenectomy may be necessary (Wszolek, Wotkowicz, & Libertino, 2008). In the event of a bowel leak, the patient will likely return to surgery to have it repaired. Although rare, a chyle leak may occur following nephrectomy (Leibovich, Mor, Golomb, & Ramon, 2002). A patient with chylous ascites may present with nausea, abdominal distension, abdominal pain, shortness of breath, and weight gain after being dismissed from the hospital (Leibovich et al., 2002). Conservative treatment is generally initiated to decrease the lymph drainage and may include a lowfat, medium-chain triglyceride diet or NPO with total parenteral nutrition, the use of octreotide, and paracentesis (Leibovich et al., 2002; Shah et al., 2008).

As a result of improved imaging studies, routine adrenalectomy is now unnecessary if the cancer has not spread to the adrenal gland (Leibovich & Blute, 2006). Increased morbidity and potential hormonal problems have been associated with nephroadrenalectomy (Wszolek et al., 2008). Symptoms of adrenal cortical deficiency include low blood pressure, change in mentation, muscle weakness, fatigue, loss of appetite, and hypoglycemia (Smeltzer & Bare, 2004).

When a patient presents with renal cell carcinoma involving a solitary kidney, nephron sparing surgery may be considered (Leibovich et al., 2006). It is imperative that nurses understand the increased risks associated with nephron sparing surgery, including hematoma, hemorrhage, and the development of urinary fistula (Hughes & Giallo-Uvino, 2007). Assessment for a urinary fistula involves monitoring surgically placed drains for increased output and sending drainage specimens if necessary to the laboratory for evaluation of the creatinine level. Discharge education following this procedure should include instructions to go urgently to the nearest Emergency Department if bleeding and/or dizziness occur. If nephron sparing surgery fails and a solitary kidney must be removed, the patient will require dialysis. A social worker would assist with discharge planning to facilitate referral to a dialysis center.

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