Internal Medicine Boot Camp Sessions

M. Junaid
 Definition of decreased urine output (oliguria)
 Questions to consider when first presented with oliguria
 Recognizing causes of oliguria
 Management of oliguria
 Recognizing life threatening complications
 It is 3:15 AM. You have just fallen asleep 2minutes ago. Page from an
RN regarding patient X.

 “Urine output has dropped to 5 ccs/hr”

 What is your response?
 A) Let me sleep and call me later.
 B) Good for you, less emptying of the Foley bag!
 C) Give the patient 200mg Lasix IV.
 D) Give the patient a 2 Liter Fluid Bolus.
 E) Nephrology Consult
 Oliguria = Urine output <400cc/day (<20cc/hr)
 Another def: urine output <0.5ml/kg/hr
 Anuria = no urine output
Prerenal
Decreased effective intravascular
volume (sepsis, hepatic failure,
anaphylactic shock, neurogenic
shock, vasodilators)
Hypovolemia (hemorrhage, GI
losses, renal losses, sugery/burns)
Impaired cardiac function (MI, PE,
cardiac tamponade, CHF,
mechanical ventilation)
Renal Postrenal
Glomerulonephritis Ureteral obstruction (stone,
(poststreptococcal, SLE/other infection, trauma)
connective tissue disorder,
malignant hyperthermia,
eclampsia/preeclampsia…)
Acute tubular necrosis (ischemia, Urethral obstruction (foley, mucus,
antibiotics, radiocontrast, pigment blood clots)
load, heavy metals, solvents)
Interstitial nephritis (drugs,
infection, neoplasm)
 ALWAYS GO SEE THE PATIENT
 Review chart to look for clues that may elicit etiology
 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:
◦ Crackles, pleural effusion
◦ JVP, CVP if pt has central line
 Especially useful in ICU for pt with central line:
 Palpate Kidneys and Bladder
◦ Rash
◦ Jaundice
 If not already done, order basic electrolytes,
 CMP (monitor changes in Cr/GFR)
 Urine studies (U/A, FeNa, BUN, Cr), to further help classify etiology
 Adjust/replace/discontinue and nephrotoxic agents.
 Also, renally dose the non-toxic meds
 Hyperkalemia: obtain EKG if elevated
 CHF/Pulmonary Edema
 Metabolic acidosis; Uremia (encephalopathy, pericarditis)
 Advanced complications of above may require dialysis

 A"- intractable acidosis;

 E"- electrolyte disarray ( K+, Na+, Ca++);
 I" - intoxicants (methanol ethylene glycol, Li, ASA);
 O"- intractable fluid overload;
 U"- uremic symptoms (nausea, seizure, pericarditis, bleeding).
 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)
 Postrenal:
◦ Treat underlying cause
◦ Post void residue- Bladder scan
◦ 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)
 Called to see a 50 year old woman POD#3 following Gastric Bypass
surgery for decreased urine output (20 ccs/hour).
 The surgeons tell you that they have given her 7 Liters of Fluid POD#1
and 6 Liters of Fluid POD#2 and that she remains oliguric despite this.
She is a total of 18 Liters fluid up.
 Her creatinine has increased from a baseline of 0.6 mg/dl to now 1.3
mg/dl.
 Foley OK? Obstruction?
 Are the kidneys getting enough juice?
 Blood Pressure, Heart Rate, Orthostatics
 BP 140/70, HR 84, unable to sit up or stand
 Filling Pressures, Neck Veins
 No central line, unable to see neck veins
 Evidence for CHF?
 TTE done but unable to get good images given body
 habitus in this 500 lbs woman.
 140Na 109Cl 15Bun
 3.8K 26HCO3 1.3 Cr
 UNa 10 mEq/L
 UK 71
 UCl 12
 Ucreat 506 mg/dl
 Uosm 560 mOsm/kg
 FENa=0.02%
 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 is an essential component of

acute/early management.

 Ultimately, regardless of pathophysiology, treating underlying cause is key

for both acute and long term management.