Young Pt On CBI

S — Situation

53-year-old male with no significant past medical history admitted after two syncopal episodes at work, found to have severe acute blood loss anemia (Hgb 3.2) secondary to 6 months of painless gross hematuria. Imaging revealed concern for multifocal urothelial malignancy involving the right kidney and bladder with possible nodal metastasis and possible left renal lesion. Post-TURBT with continuous bladder irrigation, currently being treated for MDR E. coli UTI and monitored for AKI and thrombocytopenia.

B — Background

• Presentation: Syncope ×2 with brief LOC; profound anemia on arrival

• Hematuria: Painless, 3–6 months; gross blood and clots

• Imaging:

  • CT A/P: Multifocal urothelial neoplasm in right kidney and bladder; possible nodal mets; concern for left renal lesion

  • CT Chest: No thoracic metastases

• Procedures:

  • 10/16: TURBT + right ureteral stent placement, now POD#3

• Cultures: MDR E. coli in urine

• Cardiac: TTE with new HFrEF, EF 47% (likely demand ischemia from profound anemia)

• Transfusions: 6 units PRBC this admission

• Renal: AKI post-procedure; Cr trending; urology following

• Risk Factors: Family history of RCC

• Code Status: Full code

A — Assessment

Problem	Current Status
Gross hematuria	Active; on CBI, output translucent pink
Likely urothelial carcinoma	High suspicion — awaiting pathology
MDR E. coli UTI	On Zosyn, culture-driven therapy
Acute blood loss anemia / IDA	Post-transfusion; trending CBC; Hgb target >7
AKI	Post-procedural, likely obstructive/ischemic component
Thrombocytopenia	Onc workup in progress (coags, smear, fibrinogen, B12, folate, copper)
Syncope	Secondary to profound anemia
New HFrEF (EF 47%)	Hemodynamically stable; outpatient cardiology planned
BP fluctuations	Improving; likely pain/procedural related

R — Recommendation / Plan

URO / BLEED

• Maintain Foley + continuous bladder irrigation

• CBI Titration: to clear → translucent pink urine

• Manual irrigation q shift and PRN for pain, clots, or obstruction

• Match CBI input/output; stop inflow and irrigate if suprapubic pain or no drainage

• Return to OR 10/21 for repeat TURBT — NPO at midnight 10/20

• Follow surgical pathology

INFECTIOUS DISEASE

• Continue Zosyn for MDR E. coli per culture

• Monitor fever curve and WBC

ANEMIA / HEME

• CBC q6–8 hrs

• Transfuse for Hgb < 7

• Consider IV iron once no active bleeding

• No anticoagulation due to ongoing bleeding (SCDs only)

RENAL

• Trend Cr/UOP

• Avoid nephrotoxins

• Continue CBI as above; monitor for post-obstructive changes

CARDIAC

• Orthostatic vitals pending

• Outpatient cardiology follow-up on discharge for new HFrEF

HOSPITAL MAINTENANCE

• Diet: Regular until NPO before OR

• Electrolytes: Replete PRN

• GI: Bowel regimen

• PPx: No chemical DVT ppx due to active hematuria

• Dispo: Pending clinical stability, bleeding control, and OR outcome