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DECREASED URINE OUTPUT (Oliguria). Artak Labadzhyan Mini-Lecture Powerpoints 1/30/12. OBJECTIVES. Definition of decreased urine output (oliguria) Questions to consider when first presented with oliguria Recognizing causes of oliguria Focused review of history and physical

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decreased urine output oliguria

DECREASED URINE OUTPUT (Oliguria)

Artak Labadzhyan

Mini-Lecture Powerpoints

1/30/12

objectives
OBJECTIVES
  • 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
defenition
DEFENITION
  • 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
quick considerations
QUICK CONSIDERATIONS
  • 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

NO

YES

NO

FOLEY LIKELY CLOGGED WITH SEDIMENT

PROCEDE WITH FURTHER MANAGEMENT

START FOLEY & PROCEDE W/ FURTHER MANAGEMENT

PROCEED WITH FURTHER MANAGEMENT

pathophys
PATHOPHYS
  • 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
chart review
CHART REVIEW
  • 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
examine the patient
EXAMINE THE PATIENT
  • 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
management early
MANAGEMENT (Early)
  • 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
management life threatening complications
MANAGEMENT (Life threatening complications)
  • 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
management cont
MANAGEMENT cont…
  • 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)
summary
SUMMARY
  • 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.