1. Oliguria CRASH Course Sarah Lord October 25, 2010

2.  "Reduced urine volume"  less than necessary to remove endogenous solute loads  In a patient with normal ability to concentrate urine - less than 400 mL per day or 0.5 mL/kg/h over 2 consecutive hours  In a patient with impaired ability to concentrate urine (sp gravity 1.010) - less than 1000 - 1500 mL per day Definition

3.  Oliguria is not a diagnosis, but a sign of an underlying problem  Simply attempting to restore normal urine output by administering a bolus is inadequate  Determine the underlying cause, and treat  In the end, a bolus might be all that is needed…. But don’t fall into the trap of assuming Management of the oliguric patient

4. Differential Diagnosis PrerenalRenalPostrenal Decreased effective intravascular volume (sepsis, hepatic failure, anaphylactic shock, neurogenic shock, vasodilators) Glomerulonephritis (poststreptococcal, SLE/other connective tissue disorder, malignant hyperthermia, eclampsia/preeclampsia…) Ureteral obstruction (stone, infection, trauma) Hypovolemia (hemorrhage, GI losses, renal losses, sugery/burns) Acute tubular necrosis (ischemia, antibiotics, radiocontrast, pigment load, heavy metals, solvents) Urethral obstruction (foley, mucus, blood clots) Impaired cardiac function (MI, PE, cardiac tamponade, CHF, mechanical ventilation) Interstitial nephritis (drugs, infection, neoplasm)

5.  34 yo male developed severe acute pancreatitis on holiday in Mexico (too many cervezas)  Nearly died in ICU in Mexico  Discharged home, returned to Canada, and began to experience early satiety  Large pseudocyst, endoscopic cyst-gastrostomy  Felt better for a week, then developed spiking temperatures, return of early satiety + vomiting Mr GB

6.  Called by ICU nurse at 02:00 on 8 th day of admission  On AC, Fi02 60%, RR 25, febrile at 38.6° C, tachy at 115 bpm, on TPN, NG output ~ 600 cc/last shift, requiring levophed to maintain MAP 65 mm Hg  RN reports urine output dropping – 8 cc over last hour, 14cc over hour previous, and 19 cc over hour before that  Now what?? Part I

7.  Able to maintain blood pressure with stable amounts of levophed, tachycardia consistent over last couple of days, WBC increased at 16 but decreasing, bladder pressure 10 mm Hg  Imaging shows no evidence of infected pancreatic necrosis, CXR clear, blood and urine cultures clear, creatinine and eGFR are stable, hemoglobin stable  JVP is flat (CVP trending downwards), developing 1 – 2+ pitting edema to lower extremities, skin warm and dry Part I

8.  No evidence of complication of pancreatitis (hemorrhage, infection)  No evidence of cardiac cause  No evidence of renal injury  No evidence of post-renal obstruction  Severe pancreatitis with shock/SIRS – NG and insensible losses plus third spacing leading to decreased effective circulating volume  Needs more fluid! BOLUS Part I

9.  Called to see patient in Emerg as a consult – 6 days post endoscopic cyst-gastrostomy, now with early satiety, ++ vomiting, spiking fevers up to 39° C  125/80, HR 135, temp 38.8° C, RR 22, dark concentrated urine  Feeling terrible – fatigue, abdominal pain  Now what?? Part II

10.  Clearly oliguric once foley in  Hg 160, WBC 29, Cr 126, electrolytes normal  CXR negative, urine dip negative  CT pancreas shows interval change in pseudocyst – increased in size, new heterogeneity of contents, debris, including air bubbles, ++ enhancement of rim with fat stranding around Part II

11.  Broad spectrum antibiotics initiated  pip/tazo, vancomycin  Fluid resuscitation with RL  Percutaneous drains placed in radiology  Settled, oliguria improved, but still could not eat, persistent sepsis (fever, increased WBC, malaise)  To OR for drainage and debridement!

12.  Intraoperatively, received 1.5 L crystalloid, 2 U PRBC (for preop Hg that had drifted to 78)  No significant blood loss (>300 cc)  Drained and debrided retroperitoneum  From Morrison’s pouch to hilum of spleen, to left inguinal region  Placed 4 hemovac drains and 2 penrose drains Part III

13.  POD #2 called by RN  Urine output via foley < 20 cc per hour for the last three hours – in fact, slowed to a trickle  NG output scant – replacements ordered and being given  BP 110/75, HR 105, RR 18, temperature 38.5 ° C  Now what?? Part III

14.  Stat Hg is 105 – no change from previous measurement, HMVs draining copious amounts of thin fluid with old blood but not fresh sang  Vitals stable (i.e. no trends in increased temp, HR, RR, decreased BP), JVP 2 cm ASA, looks well-hydrated  Vanco level in normal range, Cr stable  RN flushes foley – large mucus plug released, followed by gush of 300 cc clear urine! Part III

15.  What if all of the facts in the case were the same but he was tachycardic at 145 with an increased FiO2 requirement for dropping O2 saturations?  Consider PE and decreased cardiac output  Chest pain, tachycardia?  Consider MI, tamponade Part III continued