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Post-Operative Oliguria. Tad Kim, M.D. UF Surgery [email protected] (c) 682-3793; (p) 413-3222. Case. 65yo M w PVOD, POD#0 s/p right lower extremity bypass Called by the ICU for UOP 20mL over 2hrs. Initial Assessment. To the bedside, get the nurse/flowsheet Assess ABC

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Post operative oliguria

Post-Operative Oliguria

Tad Kim, M.D.

UF Surgery

[email protected]

(c) 682-3793; (p) 413-3222


Case

  • 65yo M w PVOD, POD#0 s/p right lower extremity bypass

  • Called by the ICU for UOP 20mL over 2hrs


Initial assessment
Initial Assessment

  • To the bedside, get the nurse/flowsheet

  • Assess ABC

    • Airway patent, breathing/conversant

    • VS: Afebrile, P 105, BP 99/60, Sats 96% RA

  • For any situation:

    • ABC -> Resuscitation -> H&P/Labs -> Diagnosis -> Treatment


Resuscitation
Resuscitation

  • Tachycardic, oliguric => hypovolemic

  • Get 2 large bore IV’s, place Foley & continuous monitoring

  • Fluid Bolus

    • 20mL/kg (infant) or 1L (adult) of isotonic

    • NS, LR, or Plasmalyte

    • Repeat if still dehydrated clinically

  • Once pt is resuscitated, move onto Dx


Differential diagnosis
Differential Diagnosis

  • Pre-renal (2ndary to ↓ renal perfusion)

    • Dehydration, bleeding

    • Shock 2ndary to sepsis, cardiogenic, CHF, PE

    • Abdominal compartment syndrome

  • Post-renal (obstructive)

    • Stones

    • Extrinsic compression on ureter, bladder, urethra (BPH, CA)

    • Obstructed Foley catheter


Differential diagnosis cont
Differential Diagnosis, cont.

  • Intrinsic renal

    • ATN (contrast, prolonged pre-renal, toxins, rhabdomyolysis)

    • AIN (drugs i.e. antibiotics)

    • Less common in surgical population:

      • Vascular (Wegener’s, HUS, TTP, embolism)

      • Glomerular

        • Nephritic (red cells, red cell casts)

        • Nephrotic (proteinuria, edema, HTN)


History and physical
History and Physical

  • History (straightforward)

    • Ask for h/o contrast administered, anesthetic, nephrotoxic agents, antibiotics

  • Physical

    • Fever (sepsis)

    • Signs of dehydration

    • Signs of bleeding

  • Tip: Flush the Foley (catheter obstruction)


Labs imaging
Labs/Imaging

  • Single most important lab value: FeNa

    • Send urine & serum for Sodium & Creatinine

    • Pre-renal: UNa<20, FeNa<1%, BUN/Cr >20

    • ATN: UNa>40, FeNa>2%

  • CBC if suspect bleeding

  • More complete work-up of ARF:

    • BMP, UA, Urine eos, CPK, Urine myoglobin, Renal U/S, Complement (lower in SLE)


Treatment
Treatment

  • Pre-renal: give volume (or blood)

    • Assess for CHF/HTN/edema (sign of overload)

  • Sepsis: Volume & broad-spectrum Abx

  • Contrast-induced nephropathy

    • Volume, N-acetylcysteine, (?)bicarbonate

  • Rhabdomyolysis

    • Volume, Alkalinize the urine

  • Nephrotoxin or AIN: stop the agent

    • Consider saline to flush kidneys, ↓ toxicity


Indications for hemodialysis
Indications for Hemodialysis

  • Acidosis (pH < 7.10)

  • Electrolytes (Hyperkalemia)

  • Ingestion (Dialyzable toxin overdose)

  • Overload (Refractory fluid overload)

  • Uremia

    • Manifestations of uremia i.e. platelet dysfunction, pericarditis, unexplained AMS


Take home points what to do when you re called with low uop
Take Home PointsWhat to do when you’re called with low UOP

  • “I’m on the way. Flush the Foley, draw BMP, UA, Urine sodium, Urine creatinine”

    • Assess ABC, Resuscitate if hypovolemic

      • Unless pt has CHF, safe to start w fluid challenge

    • Once resuscitated, work through “is this pre-renal, post-renal, or intrinsic?”

      • Pre: dehydrated, septic, bleeding, shock

      • Post: stone, obstructed Foley, cancer, BPH

      • Intrinsic: contrast, drugs, rhabdo

    • FeNa is the key to determining pre vs ATN

    • Complete the work-up & treat underlying prob


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