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Surgery Essay: Please note this is the updated version- discard the other

Discuss the management of oliguria

Oliguria is the passage of less than 300mL of urine per 24


hours. Poor urine output can have pre-renal, renal and post-
renal causes.

History taking can give many clues that may point towards
pre or post renal causes of oliguria. Such clues for post-renal
causes include a presenting complaint of a difficulty
initiating micturition due to pain. If the oliguria is associated
with a suprapubic pain, this is indicative of retention. A past
medical history of an enlarged prostate is suggestive of a
post-renal disease and a predisposition to retention. A drug
history of anticholinergic, alpha adrenergic and opiate drugs
might lead the patient to have problems initiating micturition
and result in oliguria.

On examination, one would look for signs of hypovolemia:


dry mucous membranes, decreased skin turgor, tachycardia.
SOB, tachycardia, raised JVP, bibasilar crepitations and
peripheral oedema are signs of heart failure and should be
watched out for. These are both signs of pre-renal causes.
Palpation of a distended bladder, dull to percussion and usually
tender, that makes the patient want to ass urine when
compressed, suggests a post-renal cause.

If the patient is in pain, conservative management by giving


anaesthesia should be tried, but if this fails catheterisation is
indicated. If the oliguria is due to post-renal causes, then the

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Surgery Essay: Please note this is the updated version- discard the other

diagnosis is confirmed by inserting the catheter: 500mL or


more should drain. If the patient already has a catheter, this is
flushed to make sure it is not blocked. If the little urine coming
out is dark, the cause is likely to be prerenal. To prove this the
urine can be dipsticked for a high specific gravity.

The fluid balance charts need to be checked. Urine output


and other losses have to be monitored: the amounts drained
from NG tubes, wound drains, and fistulae. By adding up the
urine output, these other losses and considering approximate
values for insensible losses: in sweat, lungs and faeces, one
would know the negative water balance and hence the amount
to fluid to replace. If a patient is post-op consider third space
losses. In a patient pos-op, these losses may be increased by
pyrexia. Each 1 degree rise in body temperature will require a
10% increase in body fluids administered. More fluid is needed
in the case of vomiting or diarrhoea, and if the patient has just
undergone an ileostomy, the amount of fluid lost should also be
put in the fluid balance equation. Simply put, fluid intake must
equal fluid output.

If pre-renal causes are suspected, a fluid challenge: 250-


500ml of normal saline given and the urine output checked
after one hour. If the urine output has caught up, this confirms
non-cardiac pre-renal causes. Depending on the amount lost
per day, the same amount of fluid must be given. One of the
best solutions for fluid replacement is dextrose solution 5%.
This solution is hypotonic, meaning it will be distributed
throughout the fluid compartments, such that dextrose solution
is equivalent to administering water, which distributes rapidly
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Surgery Essay: Please note this is the updated version- discard the other

and evenly throughout the entire body fluid compartments. A


dextrose saline solution can be administer to replace some of
the lost sodium, depending on the U&E. Potassium, although
lost, does not need to be replaced post-op as the serum
concentration is high due to damaged cells.

If the urine-output does not catch up, heart failure is the cause.
A bolus dose of diuretic for example 40mf frusemide will
decrease the JVP. A CVP line is necessary for knowing the state
of vascular filling and will help in the management.

Only once pre and post renal causes have been excluded that
renal causes such as acute tubular necrosis are considered.
Creatinine will be raised and the ratio of urine to plasma
osmolality will be less than one as opposed to pre-renal
problems. The renal physician should be sought.

03/02/09