Poor Urine Output

Question 1

Reduced urine output, what simple thing do you need to check?

Answer 1

The trend of reduction

Question 2

What’s an immediate thing to check with reduced urine output?

Answer 2

Blocked catheter

Question 3

With reduced urine output, what are you worried about?

Answer 3

Sepsis

Question 4

Signs of sepsis

Answer 4

Temperature
Heart rate
RR
O2 sats 
ALL THE BASIC OBS!

Question 5

Normal urine output for healthy adult

Answer 5

1ml/kg/hr

Question 6

Untreated AKI can result in

Answer 6

Hyperkalaemia
Acidosis
Pulmonary oedema
All of these can kill you

Question 7

What do you check on the fluid balance chart?

Answer 7

Adequate intake (3L/day for a normal person)
The balance, is it positive or negative?
Remember that often, stool and vomit are not accounted for. Also, NG tube may be documented somewhere else.

Question 8

Drugs that are damaging to the kidneys

Answer 8

NSAIDS
ACEi
Diuretics 
Antibiotics (vancomycin and gentamicin)
IV contrast

Question 9

What % increase in baseline creatinine constitutes acute kidney injury?

Answer 9

50%

Question 10

Questions to ask a patient with low urine output

Answer 10

Do they feel thirsty

Any symptoms of renal disease?

Question 11

Signs of post-renal obstruction

Answer 11

Poor stream
Frequency
Terminal sribbling
Hesitancy

Question 12

Signs of dehydration

Answer 12

Dry lips
Dry, cracked tongue
Tachycardic
Does the patient feel DIZZY ON STANDING (a good sign of dehydration, as often no postural drop because they compensate)
Cool peripheries and low BP (late stage)

Question 13

Signs of heart failure

Answer 13

Raised JVP
Displaced apex beat
Third heart sound
Bilateral and basal crepitations

Question 14

Signs of urine retention

Answer 14

Palpable distended bladder

BLADDER SCAN!

Question 15

How does atelectasis present and what causes it?

Answer 15

Often caused by surgical anaesthesia
Presents as crepitations
It’s alveolar collapse

Question 16

What would you expect the trend of urine output to be with a blocked catheter?

Answer 16

Sudden drop
But should just flush it anyway to check with low output
GENTLY push 50ml of fluid up the catheter, if there is any resistance this suggests a blockage

Question 17

Quick way to get potassium measurement

Answer 17

VBG

Question 18

Bloods to ask for in AKI

Answer 18

Creatinine, urea, Hb

Question 19

Urea raised suggests…

Answer 19

Dehydration

Question 20

You reckon there’s hypovolaemia, what should you initially do?

Answer 20

Fluid challenge of 250-500ml crystalloid solution stat

Monitor the response!

Question 21

How much glucose/day to avoid starvation?

Answer 21

100g

Question 22

How many ml/kg/day in typical patient

Answer 22

25ml/kg/day

Question 23

Management of acute urinary obstruction

Answer 23

Catheterisation
IV fluids
Assess renal function (monitor urea, creatinine, Hb and electrolytes)
Assess causes = DRE, urine dipstick, ensure not constipated
TWOC in the morning (NOT AT NIGHT, because can go wrong when there are fewer staff) = alpha blocker to relax the sphincter

Question 24

Which scan if you are worried about cauda equina?

Answer 24

MRI spine, looking for prolapsed disc or collapsed vertebrae

Question 25

Cause of urine 'spraying'

Answer 25

Urethral stricture | Often as a result of many cystoscopies

Question 26

Patient fluid overloaded, makes pre-renal less likely unless there is obvious pathology, so consider...

Answer 26

Renal causes e.g. hypovolaemia in surgery leading to acute tubular necrosis

Question 27

Patient with renal AKI, what do you do?

Answer 27

Refer to renal physicians Assess need for dialysis STOP nephrotoxic drugs, e.g. NSAIDs

Question 28

Complications of urethral bladder catheterisation

Answer 28

Infection Urethral trauma Scarring and stricture Bladder perforation

Question 29

Complications of chronic urinary retention

Answer 29

Dribbling UTI due to stasis Bladder stones due to stasis Hydronephrosis

Question 30

Where is renin released?

Answer 30

Kidneys

Question 31

What does renin do?

Answer 31

Stimulate production of angiotensin 1

Question 32

What converts angiotensin 1 to angiotensin 2?

Answer 32

ACE

Question 33

Which nerve controls voluntary micturition?

Answer 33

Pudendal nerve

Question 34

Which muscle contracts the bladder?

Answer 34

Detrusor

Question 35

How do you treat overactive bladder?

Answer 35

Anti-muscarinic = oxybutynin. | These inhibit the parasympathetic activity through the pelvic nerve

Question 36

Which drugs can cause urinary retention

Answer 36

Antimuscarinic Antihistamines TCA

Question 37

PSA >40 indicates?

Answer 37

High risk of metastatic prostate cancer

Question 38

How do you confirm prostate cancer?

Answer 38

Transrectal prostate biopsy (painful procedure, involving needles through rectal wall)

Question 39

Management of prostate cancer

Answer 39

Active surveillance for low risk | Radical treatment otherwise

Question 40

Patient with clot retention after TURP, which catheter should you use?

Answer 40

3-way foley (extra port is for irrigation)

Question 41

New-onset renal failure and seizures

Answer 41

``` TTP Microangiopathic haemolytic anaemia (MAHA) Thrombocytopaenia Fever Renal failure NEUROLOGICAL symptoms ```