You evaluate a 39-year-old G2P2 on postoperative day 2 following a difficult abdominal hysterectomy for endometriosis. Her surgery was complicated by hemorrhage from the left uterine artery pedicle that required multiple sutures to control bleeding. Her estimated blood loss was 500 mL. Her only other medical problem is obesity, and her prior surgeries are two cesarean deliveries. The patient now has fever, left back pain, left costovertebral angle tenderness, and hematuria. Her vital signs are height 5 ft 2 in, weight 250 lb, temperature 38.2°C (100.8°F), blood pressure 110/80 mm Hg, respiratory rate 18 breaths per minute, and pulse 102 beats per minute. Her postoperative hemoglobin dropped from 11.2 g/dl to 9.8 g/dl, her white blood cell count is 9.5 L, and her creatinine rose from 0.6 mg/dL to 1.8 mg/dL.
What is next best step in the management of this patient?
A. Order chest x-rayThe patient most likely has a ureteral injury near the location of the left uterine artery. A noninvasive renal ultrasound is fast, inexpensive, and accurate way to make the diagnosis by evaluating for hydronephrosis and/or a retroperitoneal fluid collection. Cystoscopy with retrograde intravenous pyelogram has largely been replaced by computed tomography (CT). A CT scan with contrast gives excellent information about the integrity and function of the renal collecting system; however, when the serum creatinine is elevated, intravenous contrast can cause significant renal damage and is contraindicated in those circumstances. A chest x-ray would not be helpful in making the diagnosis. Intravenous antibiotics are not indicated at this time since there is not clear evidence of an infection (normal white blood cell count). The patient has a normal drop in hemoglobin for the surgical blood loss, and does not have signs of hemodynamic instability to warrant a blood transfusion at this time.