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Artak Labadzhyan

Mini-Lecture Powerpoints
1/30/12

Definition of decreased urine output


(oliguria)
Questions to consider when first presented
with oliguria
Recognizing causes of oliguria
Focused review of history and physical
Management of oliguria

Recognizing life threatening complications

Oliguria = Urine output <400cc/day


(<20cc/hr)
Another def: urine output <0.5ml/kg/hr

Anuria = no urine output


Can signify complete mechanical obstruction of
bladder outlet or a blocked Foley

Does the pt have a foley catheter?


NO

YES
FLUSH FOLEY CATHETER
WITH 30-50CC NS

OBTAIN PVR (w/ US or cath


[will provide urine sample])

URINE OUTPUT IMPROVED?

PVR 100? ( 50 in younger pts)

YES
FOLEY LIKELY
CLOGGED
WITH
SEDIMENT

NO
PROCEDE
WITH
FURTHER
MANAGEMENT

YES
START FOLEY
& PROCEDE W/
FURTHER
MANAGEMENT

NO
PROCEED
WITH
FURTHER
MANAGEMENT

Consider the pathophysiology/causes of decreased


urine output. Three categories of causes:
Prerenal:
Volume depletion/dehydration/inadequate fluid
maintenance/Infection/sepsis
Reduced cardiac output

ICU setting: mechanical ventilation can also lead to low cardiac


output

Drugs
Does the pt have liver cirrhosis

Intrarenal:
ATN

ICU settings: Circulator shock, severe sepsis, multiorgan failure

AIN
Renal artery thrombosis/Emboli (septic [endocarditis]

Postrenal:

B/l ureteric obstruction (stones, clots, tumors, fibrosis)


Bladder outlet obstruction (BPH, tumors/retroperitoneal
mass, clots)
Foley catheter obstruction

Review chart to look for clues that may elicit


etiology (see previous slide)
History (sepsis, CHF, tumors, renal failure
etc)
Meds: diuretics, ace,
aminoglycosides/vancomycin, iv contrast,
NSAIDs
Old Labs: BUN/Cr (ratio); urine lytes; blood
cultures; vanco trough levels

Obtain new vitals, including orthostatics


Look for:

Jaundice
Crackles, pleural effusion
JVP, CVP if pt has central line
Especially useful in ICU for pt with central line:
for example a CVP of 2 can be good evidence
for hypovolemia
Palpate Kidneys and Bladder
Prostate/Cervical Exam
Rash

If not already done, order basic electrolytes,


CMP (monitor changes in Cr/GFR), and urine
studies (U/A, Na, BUN, Cr), to further help
classify etiology
Adjust/replace/discontinue and nephrotoxic
agents. Also, renally dose the non-toxic
meds

Early recognition and intervention of


potential life threatening complications
(direct or indirect causes e.g. renal
failure) is essential
Hyperkalemia: obtain EKG if elevated
CHF/Pulmonary Edema
Metabolic acidosis; Uremia (encephalopathy,
pericarditis)
Advanced complications of above may require
dialysis

Prerenal:

Treat underlying cause


If volume depleted (see physical exam): NS boluses
(500-1000ml fluid challenges) can repeat until
response (but need to monitor for fluid overload)
Avoid/be very cautious about giving lasix (again
investigation of underlying cause should drive this
decision).

Postrenal:

Treat underlying cause


Initiate Foley catheter (clear/flush catheter if already
in place)
Obtain Renal Ultrasound to assess for upper urinary
tract problems

Intrarenal:

Treat underlying causes (e.g. sever sepsis/shock)

Verify urine output w/ definition of oliguria in mind.


If pt has a Foley catheter, flushing Foley is a good initial
step. If no Foley, a PVR can help assess the need for
Foley.
A focused chart review along with a focused history and
physical can help clue in on the pathophysiology
including pre-renal/intrinsic/post-renal causes.
Recognizing life threatening complications (e.g.
hyperkalemia, acidosis, uremia) is an essential
component of acute/early management.
Decreased urine output does NOT mean lasix deficiency.
Administering lasix may actually exacerbate problem.
However very specific causes may require lasix.
Fluid boluse(s) is a good initial step (be very cautious in
CHF).
Ultimately, regardless of pathophysiology, treating
underlying cause is key for both acute and long term
management.