Oliguria and fluid management[1]


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Oliguria and fluid management[1]

  1. 1. Oliguria and Fluid Management
  2. 2. ὀλίγος-uria <ul><li>Greek prefix “few, little, scanty” </li></ul><ul><li>Two definitions: </li></ul><ul><ul><li>Urine output less than 400 cc/day or urine output or urine output less than 16.6 cc/hr (1) </li></ul></ul><ul><ul><li>less than 0.5 cc/kg/hr (2) </li></ul></ul><ul><li>One of the criteria in Acute Kidney Injury </li></ul>1) Klahr S, MillSB. Acute oliguria. N Engl J Med 1998;338: 671-675
  3. 3. © 2008 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc. 2 Figure 1. Acute kidney injury. Kellum, John; MD, FCCM Critical Care Medicine. Acute Kidney Injury in the ICU. 36(4) Suppl:S141-S145, April 2008. DOI: 10.1097/CCM.0b013e318168c4a4 Figure 1. RIFLE criteria for acute kidney injury. GFR, glomerular filtration rate; UO, urine output; dec, decrease; ARF, acute renal failure; ESRD, end-stage renal disease. Used with permission from Bellomo et al (20). *GFR changes are shown for general reference only. The criteria fulfilled by changes in serum creatinine relative to baseline.
  4. 4. Epidemiology <ul><li>ARF occurs in approximately 5-8% of hospitalized patients. </li></ul><ul><li>15-30% of patients admitted to the ICU </li></ul><ul><li>Mortality in ICU patients as high as 60%. </li></ul>
  5. 5. ICU admissions (excluding ESRD) 576 No AKI on admission 330 (57.3% of all ICU patients) Never develop AKI 197 (34.2% of all ICU patients) Ever AKI 379 (65.8% of all ICU patients ) AKI on admission 246 (42.7% of all ICU patients) New AKI 133 (40.3% of patients without AKI on admission) Partial renal recovery* 51 (13.5% of AKI patients) Complete renal recovery* 225 (59.4% of AKI patients) No renal recovery* 103 (27.2% of AKI patients) Garzotto, F, Pasquale P, RIFLE-Based Data Collection/Management System Applied to a Prospective Cohort Multicenter Italian Study on the Epidemiology of Acute Kidney Injury in the Intensive Care Unit. 2011
  6. 6. Oliguria <ul><li>A clinical manifestation of: </li></ul><ul><ul><li>“perfect” organ function </li></ul></ul><ul><ul><li>Kidney injury </li></ul></ul><ul><ul><li>Distal obstruction </li></ul></ul>
  7. 7. Oliguria <ul><li>Causes of oliguria separated into 3 categories </li></ul><ul><ul><li>Prerenal </li></ul></ul><ul><ul><li>Renal </li></ul></ul><ul><ul><li>Postrenal </li></ul></ul>
  8. 8.   Aetiology of acute renal failure. Fry A C , Farrington K Postgrad Med J 2006;82:106-116 ©2006 by The Fellowship of Postgraduate Medicine
  9. 9. Prerenal Oliguria <ul><li>“ Lack of urine output in the acutely hypovolemic patient is renal success, not renal failure” – Ronald Maier </li></ul><ul><li>The dysfunction is systemic. </li></ul><ul><li>Prolonged renal success can eventually lead to renal failure. </li></ul><ul><li>Responsible for 30-40% of cases of oliguria in the ICU </li></ul>
  10. 11. Oliguria <ul><li>Pre-renal conditions </li></ul><ul><ul><li>Hypovolemia </li></ul></ul><ul><ul><li>Mechanical ventilation </li></ul></ul><ul><ul><li>Aortic Stenosis </li></ul></ul><ul><ul><li>End-Stage Cardiomyopathy </li></ul></ul><ul><ul><li>Drugs that impair auto-regulation </li></ul></ul><ul><ul><ul><li>NSAIDS (ketorolac), ACE-I, ARBs </li></ul></ul></ul>
  11. 12. Pre-renal Oliguria <ul><li>Treatment </li></ul><ul><ul><li>Treat the underlying cause. </li></ul></ul><ul><li>Prolonged or severe pre-renal conditions can lead to renal injury and oliguric failure. </li></ul>
  12. 13. Renal injury <ul><li>Less common than pre-renal ARF </li></ul><ul><li>Three locations of injury: </li></ul><ul><ul><li>Glomerulus </li></ul></ul><ul><ul><li>Tubules </li></ul></ul><ul><ul><li>interstitium </li></ul></ul>