Low Urine Output. Hospitalist Team Intern Didactics M. Jackson, 2007

Transcription

1 Low Urine Output Hospitalist Team Intern Didactics M. Jackson, 2007

2 Outline RN call- what to ask? Level of acuity- is this an emergency? Ddx Focused H & P- what to check signout for? ask? look for on exam? Work-up- what labs/studies should be done overnight? Management- what is the overnight plan?

3 RN call VITALS, APEARANCE AND MENTAL STATUS eg. oh yeah, patient does seem a little confused and was complaining of SOB ONSET eg. patient is here being worked up for oliguria RECENT EVENTS eg. patient just had foley d/c d that afternoon

4 Is this an emergency? Indications for emergent HD: HAVE-TO-P Hyperkalemia (k >6.5 w/ ecg changes) Acidosis (bicarb <15, ph <7.2) Volume overload Encephalopathy Toxins (methanol, ethylene glycol, theophylline, aspirin, lithium ) hemorrhagic diathesis Pericarditis

5 Definitions oliguria < cc/d anuria < cc/d Uremia BUN > 100 CrCl < 10 cc/min Sxs: AMS, n/v, fatigue, anorexia, weight loss, muscle cramps, pruritus Findings: anemia, acidosis, hyperk, Ca/phos abnormalities, hypothyroidism, pericarditis

6 H &P For focused H & P should have a ddx in mind...

7 Ddx PRE-RENAL hypovolemia (overdiuresis, inadequate nutrition/ hydration, infection, tachypnea, vomiting/ diarrhea) meds (nsaids, acei, dye, cyclosporine) CHF, cirrhosis/hrs INTRINSIC RENAL ATN (advanced pre-renal, rhabdo, hemolysis, aminoglycosides, ampho) AIN (infection, nsaids, sulfa, b- lactam) Vascular (thrombosis, cholesterol emboli, vasculitis) POST- RENAL BPH Crystals (acyclovir, MTX, triamterene, indinavir, sulfonamides) Catheter obstruction Pelvic mass anti-cholinergic meds

8 H & P, focused: HISTORY Before you see the patient PMH signout should include relevant PMH (CKD, CHF, cirrhosis, nephrolithiasis, gout, BPH, neurologic dz, allergies) check webcis for old renal u/s Hospital course signout should include issues during current hospitalization (infection, procedures, contrast studies), recent events (foley d/c d) and meds/ivf check webcis for Cr/BMP trend and recent UA; eclypsis for UO trend

9 H & P, focused: HISTORY Patient interview Sxs of fluid overload (sob, orthopnea, edema) dehydration (thirst, dizziness, orthostasis, vomiting/diarrhea), obstruction (urgency, frequency, hesitancy, weak stream stone (flank pain, hematuria) rash

10 H & P, focused: PHYSICAL MS confusion Neck jvd Heart muffled hs, gallop, rub Lung rales, rub GI/GU suprapubic fullness, rectal tone, enlarged prostate, CVAT LE edema (check sacrum also) Derm maculopapular rash, embolic phenomena, palpable purpura, livido reticularis

11 Work-up UA BLAND pre-renal, post-renal GRANULAR CASTS ATN RBC CASTS glomerulonephritis, HTN emergency WBC CASTS AIN, pyelo EOS allergic AIN, atheroembolism Urine lytes, Cr FeNa = (UNa/UCr) / (PNa/PCr) <1% pre-renal Urine protein

12 Work-up BMP CXR If suspect CHF, volume overload ECG If K > 5.5 Abg If concern for acidemia Renal u/s +/- doppler If suspect obstruction or vascular pathology

13 Management Plan O2 If volume overloaded: Lasix, ntbp (check that not getting ivf!) If volume deplete: IVF Foley (change or place) for dx as well as monitoring

14 Management Plan Hyperkalemia: Stabilize myocyte membrane If QRS widening or loss of P Ca gluconate 10cc of 10% sol IV over 2 min increases threshold potential to level of resting membrane potential which is elevated in hyperk; onset < 5 min Temporary K+ shift into cells Na bicarb, onset < 5 mins 10u RHI + 2 amps D50, onset 30 min albuterol neb, onset 30 min K+ elimination kayexalate 30g po/pr, loss through GI tract lasix, loss through kidney

15 Management Plan Bleeding, uremic platelets: ddavp 0.3 mcg/kg iv, onset 4hr, lasts 24 hrs conjugated estrogen (0.6 mg/kg iv qd x5)

16 Ask for help When to call resident/med consult? Your resident should know about any patient with unstable VS or AMS When to call GU? If both RN and MD fail in placement of catheter; must try coudet first When to call Renal? If pt meets any criteria for emergent HD