Oliguria and Anuria Hot Case

GENERAL APPROACH

Type of renal failure

  • Acute (usually multi-factorial)
  • Chronic (e.g. dialysis dependent) or
  • Acute on Chronic (e.g. post-renal transplant)

Causes

  • Pre-renal – hypovolemia, any cause of shock, sepsis, renovascular disease
  • Intra-renal – nephrotoxins, urine for casts + protein, sepsis, rhabdomyolysis, nephritic/nephrotic syndromes
  • Post-renal – catheter blocked, pelvic rim surgery, blocked ureters, intraabdominal pressure, hydronephrosis

INTRODUCTION

CUBICLE

  • CRRT or IHD
  • bags of dialysate fluid – lactate or bicarbonate buffer
  • TMP
  • settings
  • anticoagulation strategy and filter life-spans

INFUSIONS

  • inotropes/vasopressors to maintain organ perfusion
  • N-acetylcysteine for imaging/ procedures with contrast
  • sodium bicarbonate for metabolic acidosis
  • systemic anticoagulation (for RRT or other indication)

VENTILATOR

  • oxygen requirement (fluid overload with pulmonary oedema)
  • PEEP

MONITOR

  • CVP (number, waveform)
  • renal perfusion pressure (MAP-CVP)
  • ECG (signs of hyperkalaemia)
  • arterial trace (pressure)

EQUIPMENT

  • dialysis access — catheter (check previous insertion sites e.g. dressings), AV fistula, Tenckhoff peritoneal dialysis catheter
  • IDC or lack of (colour, volume, no bag suggests chronic renal failure)
  • recent intra-abdominal pressures (manometer attached to IDC)
  • IABP (low position may cause oliguria)

QUESTION SPECIFIC EXAMINATION

  • hands -> head -> chest -> abdo -> feet -> back

-> cardiovascular
-> respiratory
-> abdominal (kidneys, organomegaly, distension)
-> compartments
-> end-organ perfusion

  • neurological

-> paralysed
-> quick examination
-> unconscious
-> conscious

Questions

  • urine output over last 8 hours?
  • urine dipstick and microscopy?
  • paired serum and urinary electrolytes?
  • has IDC been flushed recently?
  • recent exposure to nephrotoxic agents?

RELEVANT INVESTIGATIONS

  • CXR (APO, check IABP isn’t too low)
  • ABG (metabolic and electrolyte derangements)
  • pregnancy test (eclampsia?)
  • urea and creatinine
  • compartment pressures? (if suspect limb or abdominal compartment syndrome)

OPENING STATEMENT

  • = “Multi-factorial” and list headings of causes -> clinical signs associated with list
  • “There is evidence of ESRF…”

DISCUSSION

Renal disorders

RRT


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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