Sanjeev ghai Income tax B

Information about Sanjeev ghai Income tax B

Published on October 13, 2014

Author: praveen114731

Source: authorstream.com

Content

DECREASED URINE OUTPUT (Oliguria): 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 Management of oliguria Recognizing life threatening complications OBJECTIVES 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 DEFENITION QUICK CONSIDERATIONS: QUICK CONSIDERATIONS Does the pt have a foley catheter? YES NO 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 YES NO NO FOLEY LIKELY CLOGGED WITH SEDIMENT PROCEDE WITH FURTHER MANAGEMENT START FOLEY & PROCEDE W/ FURTHER MANAGEMENT PROCEED WITH FURTHER MANAGEMENT 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 PATHOPHYS 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 CHART REVIEW   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   EXAMINE THE PATIENT 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 (Early) 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 (Life threatening complications) 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) MANAGEMENT cont… 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. SUMMARY

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