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HANNA
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Trauma & Oliguria
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06.14.04 (5 years ago)
#1
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Theme: Trauma & Oliguria
Options
A Percutnaeous nephrostomy
B Suprapubic cystostomy
C Urethral catheterization
D Blood transfusion
E Fluid challenge
F 500-ml of IV mannitol
G Walk around
Instructions
For each of the patients below, choose the most appropriate option from the list of Options above. Each option may be used once more than once or not at an.
811 Following an elective herniorrhaphy, a 67-year-old man is unable to pass urine, when a nurse hands him a small bottle for microscopic studies. He is otherwise well.
812 A 34-year-old woman presents with right-sided loin pain & oliguria. An intravenous urogram shows right-sided dilated calyces and hydroureter.
813 A man involved in a mining accident presents with oliguria & passing dark brown urine.
814 A 45-year-old man sustained a pelvic fracture & now presents with oliguria, pulse rate of 120-beats/min & BP-70/50-mmHg.
815 A 23-year-old man who sustained a pelvic fracture is unable to pass urine. O/E he has abdominal tenderness & fullness & blood on the urethral meatus.
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sajida
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06.14.04 (5 years ago)
#2
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1--g
2--a
3--e or f
4--d
5--b
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HANNA
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06.14.04 (5 years ago)
#3
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813 A man involved in a mining accident presents with oliguria & passing dark brown urine.
>>>>>..I THINK WE AGREED F BEFORE ON THIS QUESTION (OSMOTIC DIURESIS)
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Satman
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06.14.04 (5 years ago)
#4
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AGREE .. but for 813 .. ??? no idea ..
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tania
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06.15.04 (5 years ago)
#5
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5.y not try cathetersation
yes we agreed on osmmotic diuresis
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HANNA
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06.15.04 (5 years ago)
#6
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because urethra is injured even if it is a pratial rupture........trying to put a catheter will make it complete and danger of going outside bladder and to the peritoneum.
so rule is not to even try a catheter in case of suspected rupture urtra.....rather go for suprapubic cystostomy.
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sajida
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06.15.04 (5 years ago)
#7
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b/c presence of blood on uretheral meatus ,we should not try catherisation
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Drstanilo
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04.14.05 (4 years ago)
#8
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But why osmotic diuresis for question 813. Couldsomeone please explain.....?
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mony
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04.14.05 (4 years ago)
#9
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| Drstanilo wrote: |
| But why osmotic diuresis for question 813. Couldsomeone please explain.....? |
Rhabdomyolysis<myoglobinuria<tubular obstruction<Acute renal failure
Therapy :alkalinization of urine and increase urine flow facilitates myoglobine excretion.
Increase urine flow -by nonelectrolyte solute diuresis=osmotic diuresis =Mannitol
Also use Sodium Bicarbonate to alkalinize the urine
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Drstanilo
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04.15.05 (4 years ago)
#10
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Thanks Mony but still a bit confused, in acute renal failure secondary to rhabdomyolysis, line of management is often:
Large volumes of fluid up to 12L/d
IV mannitol or urinary alkalinization; see OHCM6 pg 281. Don't you think fluid challenge should be a better option in this case?
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mony
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04.15.05 (4 years ago)
#11
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| Drstanilo wrote: |
Thanks Mony but still a bit confused, in acute renal failure secondary to rhabdomyolysis, line of management is often:
Large volumes of fluid up to 12L/d
IV mannitol or urinary alkalinization; see OHCM6 pg 281. Don't you think fluid challenge should be a better option in this case? |
Management steps include:
increasing a fluid challenge to ensure that the urine output is at least 1-2 mls/kg/hour
alkalinization of the urine:
reduces urinary crystallisation of haemochromogens
add sodium bicarbonate to the resuscitation fluid at 25 mmol/litre of fluids
forced diuresis:
mannitol added to the fluids
12.5 g/litre of fluids
I don't think that just fluid challenge is enough.It's needed alkalinization of urine because there are lactic acidosis, increased uric acid and also it decreases myoglobine cristallization on tenal tubes. Mannitol is an osmotic diuretic,inhibits tubular reabsorption of electrolytes by increasing osmotic pressure of glomerular filtrate. Increases urinary output.
Mannitol has many pros and cons but there is no doubt about large fluid volume and urine alkalinisation(I don't remember if alkalinization was an option).
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Drstanilo
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04.15.05 (4 years ago)
#12
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since these two approaches (fluid challenge, iv mannitol) are included in the options, how then do we chose the correct one from the two. Note that OHCM6 pg281 even specified large volumes of fluid "up to 12litres per day" whereas in the option we have "IV 500ml mannitol" . How then do we get this 12Litres of fluid per day from just 500ml of mannitol? Fluid challenge means just giving a specified(usually large) volumes of fluid within a given time before probably stabilizing the amount of fluid administered....I think fluid challenge is the better option. more comments!
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akanksha
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04.16.05 (4 years ago)
#13
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I agree wid Drstanilo!
the immediate life saving step for rhabdomyolysis is rapid expansion of intravascular volume wid large
quantity of crystalloids.
while '12 ltrs of fluid' is absolutely essential, '500 ml of mannitol' may be desirable but not absolutely essential.
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