1. Green Urine!? COPYRIGHT © 2013, ALL RIGHTS RESERVED From the Publishers of

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3. Copyright © 2013 Case A 70 yo woman presents for elective L4-L5 spine decompression surgery (back pain)  Healthy  Denies cigarette smoking, FHx, DM, Hypertension. Unaware of lipid status  No family hx of thrombotic disorder  No use of food supplements, additives,  Activity limited by back pain  Dysuria last week: UA and culture-no infection

4. Copyright © 2013 Case Preop Exam  Comfortable  Ht 5’8”, wt 150 lbs  BP 120/80 right and left arm, HR 70 (sinus)  S1, S2 normal, No murmurs, S3, S4  Abd soft, bowel sounds normal  Distal pulses intact. No edema

5. Copyright © 2013 Case Labs:  CBC: wnl  Electrolytes: wnl  Renal and hepatic function: wnl  Urine analysis  Coags normal

6. Copyright © 2013 Case It was your impression that the risk of surgery was low and you suggest that surgery proceed.

7. Copyright © 2013 Case Surgery under general endotracheal anesthesia begins At 1.5 hours into surgery her urine color changes from clear yellow to vivid green

8. Copyright © 2013 Case You are called by the OR staff because you “cleared” her for surgery. They ask for advice. While surgery is going well one question is should surgery be terminated?

9. Copyright © 2013 Case Choices : Terminate the surgery as soon as can safely be done Continue surgery but get stat liver function studies Continue surgery but increase iv fluid repletion Continue surgery and get hemolysis panel Continue surgery and no further testing

10. Copyright © 2013 Case 70 yo woman healthy L-4, L-5 decompression (elective) Normal preop labs Dysuria 1 week ago, UA, urine culture: no infection Intraoperative green urine

11. Copyright © 2013 Clinical significance of perioperative urine color change http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2596703

12. Copyright © 2013 Red urine in the perioperative period Trauma (foley) Medications  Rifampin  Pyridium Foods  Beets, blackberries, rhubarb

13. Copyright © 2013 Orange urine in the perioperative period Dehydration Cholestasis, liver disease Medications  Rifampin  Pyridium

14. Copyright © 2013 Dark brown urine in the perioperative period Hemolysis Cholestasis, liver disease

15. Copyright © 2013 Green urine in the perioperative period Urine infection (pseudomonas) Food dyes  St Patricks day Asparagus Chlorets

16. Copyright © 2013 N Engl J Med Oct 5, 1978

17. Copyright © 2013 N Engl J Med, Jan 25, 1979

18. Copyright © 2013

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