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Magdy M Khalil, MD, EDIC Prof. Pulmonary& Critical Care Medicine Challenges in RICU: Oliguria.

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Presentation on theme: "Magdy M Khalil, MD, EDIC Prof. Pulmonary& Critical Care Medicine Challenges in RICU: Oliguria."— Presentation transcript:

1 Magdy M Khalil, MD, EDIC Prof. Pulmonary& Critical Care Medicine Challenges in RICU: Oliguria

2 Oliguria: causes  Pre-renal (Hypo-perfusion)  Hypovolemia  ↓ COP  Relative hypovolemia ( vasodilatation in response to inflammation)  Post-renal  Obstruction of the bladder neck, neurogenic bladder, or therapy with anticholinergic drugs  Blood clots, calculi  Urethritis with spasm  ‘Intrinsic’ renal failure  Pre-renal failure.  Allergic interstitial nephritis  Autoimmune pulmonary- Renal syndromes Oliguria : UO≤ 0.5 mL/kg/h Anuria : UO< 50 mL /d

3 AKI: Definition Non-oliguric AKI

4 AKI: Diagnosis  Comprehensive history,  Observation chart,  Clinical examination, and  A review of recent investigations and drug therapies R/O obstruction Consider pre- renal Think of renal

5 AKI: Clinical examination  Full bladder/patent catheter  Neck veins  Signs of hypovolemia:  tachycardia,  dry mucous membranes,  hypotension,  low CVP,  peripheral hypoperfusion (altered mentation and cold clammy skin with delayed capillary return)  Heart

6 AKI: Investigations  AKI biomarkers  S. creatinine  NGAL (neutrophil gelatinase-associated lipocalin), IL-18, KIM-1, Cystatin C, and L-FABP  BUN/creatinine (>20 ?pre-renal, <10-15?ATN)  Urine: concentrated, SG>1.018, osmolality >350 mosm/l; urine Na <10 mmol/l and the FeNa<1% ?pre-renal  Ultrasound

7 AKI: Management  Ensure a non-obstructed outlet,  Treat underlying illness,  Maintain an adequate renal perfusion,  correction of fluid depletion  reversal of hypotension  Avoid nephrotoxic agents,  Adjust dose of renally excreted drugs, and  Renal replacement therapy (RRT) should an indication arise.

8 AKI Management: Fluid therapy  Type: crystalloids vs colloids (high MW hetastarch×)  Rate: 10–15 ml/kg (large bore cannula)  End points:  MAP (65-90 mmHg),  CVP (8-12 mmHg),  pulse pressure variation,  CO,  ScvO 2 /SvO 2,  PAOP,  UO,  lactic acidosis, and skin perfusion.  RI  Safety: hypervolaemia is avoided Fluids should be given early & targeted 1)Type, 2)Rate, 3)End points, 4)Safety limits

9 AKI : Vasoactive and inotropic drugs  Vasopressors :  norepinephrine  phenylephrine  low-dose vasopressin, terlipressin  Ino-constrictors:  epinephrine  dopamine  Inodilators:  Dobutamine  dopexamine  Livosimendan  Chronotropy  Intra-aortic balloon counterpulsation  Natruritic peptides The choice of drug should be driven by hemodynamic characteristics of the patient

10 Low-dose dopamine “renal dose”  1–3 mcg/kg/min produces preferential dopaminergic (and β -adrenergic effects) over α -adrenergic actions (>5 mcg/kg/min) and thereby causes renal vasodilation and increases urinary output.  Improve UOP but confers no significant protection from renal dysfunction  Fenoldopam mesylate is a selective dopamine α -1 receptor agonist that can improve renal blood flow without increasing cardiac output

11 AKI: Diuretics  Diuretics have traditionally been used to ‘convert’ the oliguric state to non-oliguric…..? ATN.  The use of diuretics should be restricted to the treatment of volume overload and occasionally hyperkalaemia  Caution is advised as there is reasonable concern that excessive reliance on diuretics might delay initiation of RRT.

12 AKI: RRT  Clinical uraemia,  Severe hyperkalaemia,  Persistant acidosis, and  Non-responsive volume/fluid overload Early vs late!

13 AKI: Dose adjustments  Nephrotoxics : avoid  Loading dose: OK  Maintenance: ↑ intervals/ Dialysable vs non dialyasable  Creatinine clearance ?  Dilution effect of FT !

14 AKI: Contrast nephropathy  Prevention:  Acetyl cysteine  Bicarbonate  Theophylline  Hydration Avoid if unnecessary !

15 CVP, PCWP, CI Bl. chemistery Urine analysis Fluid resuscitation Vasopresors Inotropes Exclude volume overloadDiuretics Exclude obstruction Diagnostic workup ? Diuretic ?RRT Pre-renal? U Catheter/flush US Hypovolemia HF Inotropy Inodilation Specific therapies Management of oliguria/anuria Response Adjust therapy Renal? Concurrent pathology

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17 Best wishes Magdy Khalil, MD, EDIC


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