The Case of the “Hidden” IV

A 55-yr-old man is admitted for emergency laparatomy after a stab to his abdomen. He is hemodynamically stable. He has no history of note, except for a previous stab, again, to his abdomen. His previous anesthesia and surgery have been uneventful. He arrives in the operating room with a 20-gauge (G) IV in his hand, which is seen to work well. He does not like needles and, because he is considered stable, routine rapid sequence induction is initiated without any problems. After induction, a 14-G peripheral IV is placed in the right hand and attached to a Hotline Fluid Warmer (SIMS Level 1, Inc., Rockland, MA) for possible blood transfusion. A central vascular line is inserted into the right subclavian vein without any problems. The CVP is running well and you aspirate back blood easily from all lumens. At the surgeon’s request, the left arm with the 20-G IV is tucked alongside the patient’s body. The right hand, with the 14-G IV, is placed “out” at 90 degrees to his body. The surgery commences and repairs of both small and large intestines are needed. Four hours into the operation, the urine output decreases. The surgeon tells you there is no urine in the bladder. The central venous pressure (CVP), as measured with your triple-lumen IV set, is within normal limits. Through the 20-G IV (the IV is now seen to be working “great”), furosemide 10 mg is given and a dopamine drip is commenced. After 30–40 min, no improvement in urine output is seen. The patient is still cardiovascularly stable with a normal CVP, but the urine output has only been 3 ml in the last hour. You give more furosemide and increase your dose of dopamine again via your 20-G IV. However, 30 min later there is still no improvement in urine output. Before contemplating other drugs/doses/fluids what should you do?