Oliguria caused by dehydration in combat trauma (case series)

Abstract

Background. A combat gunshot wound is significantly different from a civilian trauma. It is characterized by the prevalence of penetrating injuries, which increases the volume of blood loss at the pre-hospital stage, and the destruction of large masses of muscle tissue (rhabdomyolysis), which leads to acute kidney injury. Moreover, combat trauma occurs in conditions of chronic background stress as a result of severe emotional and physical strain, uncomfortable weather conditions, and deprivation of sleep, drinking and food. So, such a phenomenon as voluntary dehydration is common among soldiers in combat conditions. In wounded, oliguria is often considered a result of acute kidney injury, but it can also be a symptom of severe dehydration. The purpose of our work was to analyze three clinical cases of oliguria caused by dehydration in wounded with combat trauma to better understand the severity of the condition of such victims and to improve medical aid for them. Materials and methods. The article describes three cases of men aged 35, 50 and 44 years with combat gunshot wounds to the extremities, who were admitted to the tertiary care hospital on the second day after the injury with oliguria (0.18–0.19 ml/kg/hr) and high creatinine (333 to 457 μmol/L). Results. All three patients were conscious, breathing spontaneously, had stable hemodynamics, and moderate anemia after pre-hospital blood transfusions. Focused ultrasound study revealed hyperdynamic left ventricle and small inferior vena cava with complete inspiratory collapse, which suggested hypovolemia. Upon further investigation of the medical history, patients admitted not drinking any liquid for one to two days prior to injury. Tissue hydrophilicity test was conducted which showed severe dehydration in all three cases. Infusion volume was calculated using P.I. Shelestiuk nomogram (modified by O.V. Kravets et al.) and amounted to 60 ml/kg of balanced crystalloid solutions. Upon starting rehydration, diuresis was restored within two hours and amounted to 0.7–2.1 ml/kg/h in all three patients. Creatinine levels normalized in 2–4 days. Patients were transferred to another hospital in a moderate condition in 4–5 days. Conclusions. Oliguria is a frequent complication of combat gunshot injury. Although it is most often associated with acute kidney injury from rhabdomyolysis, it should also be considered that in a combat environment, soldiers’ access to water may be limited and the injury may be accompanied by dehydration. In the cases presented, the differential diagnosis of the causes of oliguria in the wounded made it possible to detect signs of severe dehydration, abstain from the inappropriate use of saluretics, quickly compensate for the fluid deficit, and to avoid the development of kidney damage and the need for renal replacement therapy.