Post Operative Oliguria

Post-Operative Oliguria

Post-Operative Oliguria

Definitions
Oliguria - <0.5 cc/kg per hr in adult
About 30-70 cc/hr
Children less than 10kg: <1 cc/kg per hr

Anuria - <100cc/24hrs
Acute renal dysfunction oliguria and
increase in Creatinine (>1 mg/dl from
baseline)

Post-Operative Oliguria

Case Presentation
65y M w PVD, POD#0 s/p RLE bypass
Called by the ICU for UOP 20mL over 2hrs

Post-Operative Oliguria

General Approach
Go see patient, talk with nursing staff, get flowsheet
ABC (evaluate mental status)
Resuscitate - does pt have adequate IV access, does the pt
need Foley, NGT, continuous monitoring?
H&P
Physical examination
Order appropriate labs/tests
Diagnose and treat
Communicate plan with team and patient

Post-Operative Oliguria

Case: Assessment & Resuscitation

AAOx3, afebrile, P 105, BP 100/60, O2 sat 96% RA

Tachycardic, oliguric = hypovolemia
Ensure adequate IV access
Fluid bolus
While pt is receiving bolus, continue the evaluation

What are potential causes? What exam findings/tests

will help you make a diagnosis?

Post-Operative Oliguria

DDx

Pre-renal (2/2 renal perfusion)

Dehydration, bleeding
Shock 2/2 sepsis, cardiogenic
Abdominal compartment syndrome
Renal artery stenosis
Post-renal (obstructive)
Obstructed Foley catheter
Extrinsic compression on ureter, bladder, urethra (BPH, CA, hematoma)
Stone
Intrinsic renal
ATN (contrast, prolonged pre-renal, toxins, rhabdomyolysis)
AIN (drugs i.e. antibiotics)
Less common in surgical population:
Vascular (Wegeners, HUS, TTP, embolism)
Glomerular
Nephritic (red cells, red cell casts)
Nephrotic (proteinuria, edema, HTN)

Post-Operative Oliguria

H&P
Focused history: time since surgery, surgical
complications, anesthesia history (any periods of
hypotension during surgery?), recent medications,
recent h/o contrast, check fluid balance (include
operative period and even pre-operative period)
Physical: signs of bleeding, signs of dehydration,
look at urine

Tip: Flush the Foley (catheter obstruction)

Post-Operative Oliguria

Labs
Initial labs:
CBC - ?bleeding?
BMP, urine Na & Cr, U/A
Note: if pt has been on diuretics, send for urea
instead of Cr
Additional studies: Urine Eos, CPK, Urine myoglobin,
Renal U/S
As suspected: septic workup, MI workup

Interpretation of FeNa:
Pre-renal:
UNa<20, FeNa<1%, BUN/Cr >20
ATN:
UNa>40, FeNa>1%

Post-Operative Oliguria

FeNa Calculation
FENa = UNa * PCr / PNa * UCr x 100
Online calculators

Post-Operative Oliguria

Studies
Renal Ultrasound evaluate renal blood
flow
Central catheter to evaluate CVP,
Swan-Ganz catheter
Bladder pressures (for Abd
Compartment Syndrome)
Via foley, >20 abd HTN, >40 requires
intervention

Bladder US or IV pyelogram

Post-Operative Oliguria

Post-Op Oliguria: Treatment

Pre-renal: resuscitation, improve CO
Post-renal: fix the obstruction
New foley, suprapubic tube, nephrostomy tube

Sepsis: resuscitate & broad-spectrum abx

Contrast-induced nephropathy: IVF, Nacetylcysteine, +/- bicarbonate
Nephrotoxin or AIN: stop the agent

Post-Operative Oliguria

Indications for Hemodialysis

Acidosis (pH < 7.10)

Electrolytes (for example, hyperkalemia)
Ingestion (toxins)
Overload (fluid overload)
Uremia

Post-Operative Oliguria

Take Home Points

What to do when youre called with low UOP

Go see the patient

Always start with your ABCs
Resuscitate
Oliguria ddx: pre-renal, post-renal, intrinsic
Look for bleeding
FeNa can help