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Category: Critical Care Medicine-Renal, Electrolyte and Acid Base Disorders--->Oliguria and Polyuria
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Question 1# Print Question

A previously healthy 18-year-old woman presents to the emergency department 4 hours ago with headache and photophobia. Her parents state that her symptoms began as a mild fever and headache, and today, she appears to be a bit confused and has been urinating a lot. On physical examination, she is alert and oriented but slow to answer questions. There are no focal neurological signs. Her labs reveal elevated leukocytosis and hypernatremia. Blood cultures were sent.

What is the next BEST step in management?

A. Start broad-spectrum antibiotics
B. Obtain urine sodium, chloride, creatinine, and osmolality
C. Obtain spinal fluid sample
D. Obtain CT scan of head

Question 2# Print Question

A 45-year-old man is admitted for urgent laparoscopic cholecystectomy for severe cholecystitis. His medical history was significant for chronic kidney disease and moderate to severe pulmonary hypertension which is being treated with continuous epoprostenol infusion at home. Intraoperative transesophageal echocardiogram showed depressed right ventricular systolic function. Intraoperative course was complicated by blood loss, requiring 2 units of packed red blood cells and 500 mL of lactated ringer. Postoperatively, he remained sedated and intubated and transferred to the intensive care unit (ICU) for close monitoring. His home-dose IV epoprostenol was continued intraoperatively and in the ICU. During his first postoperative day, he made minimal urine. Oxygen saturation is 100%, and estimated pulmonary artery pressure is at baseline, however, central venous pressure has increased. 

Which of the following is the next BEST step in management?

A. Repeat transesophageal echocardiogram to reassess the right ventricular function
B. Obtain a nephrology consult to start continuous renal replacement therapy
C. Switch intravenous epoprostenol to inhaled epoprostenol
D. Administer a bolus of albumin in to improve the urine output

Question 3# Print Question

A 62-year-old woman with medical history of hypertension and smoking presents to the hospital after sudden onset of severe headache followed by collapse. In the emergency department, CT scan of the head showed diffuse subarachnoid hemorrhage and CT angiogram revealed a left middle cerebral artery aneurysm. An extraventricular drain is placed by neurosurgery team. On day 7 of hospitalization, the patient develops new aphasia. The urine output has been 1800 mL in the past 3 hours, while the serum sodium has decreased from 138 to 132 mmol/L. 

What is the best next step in management to address this high urine output?

A. Start fluid restriction and continue to monitor the sodium every 6 hours
B. Aggressively replace volume deficit by giving bolus of 2 L of 0.9% normal saline and recheck sodium after the bolus
C. Start fludrocortisone and salt tablets
D. Stop maintenance intravenous fluids and give 250 mL of 3% hypertonic saline, recheck sodium level after administration
E. Continue administration of intravenous normal saline for maintenance and to replete urine output. Give a 250 mL bolus of 3% hypertonic saline

Question 4# Print Question

A 52-year-old man with history of bipolar disorder and headaches is admitted for elective pituitary macroadenoma resection in the early morning. Following the otherwise uncomplicated neurosurgical procedure, he is admitted to the ICU for postoperative observation. You receive a call near midnight reporting that urine output has increased to 1000 mL in the past 3 hours while serum sodium increased from 142 to 146 mmol/L.

What are the next steps you should take to prevent worsening of hypernatremia? 

A. Start maintenance fluids with dextrose 5% in water until sodium level returns to baseline
B. Ask for the value of urine specific gravity and if <1.005, administer a dose of desmopressin while asking patient to drink to thirst
C. Increase rate of maintenance IV fluids with 0.9% normal saline
D. Institute fluid restriction to 1.5 L/d and recheck sodium in the morning before rounds
E. Call neurosurgery and ask if 3% hypertonic saline was given intraoperatively

Question 5# Print Question

A 75 kg, 70-year-old male with a history of hypertension, coronary artery disease, and benign prostatic hypertrophy gets admitted to the ICU after a partial colectomy and liver resection for colon cancer. Placement of indwelling urinary catheter placement was challenging due to his enlarged prostate causing some hematuria. The operative procedure was complicated by bleeding, requiring 4 units of packed red blood cell transfusion. Postoperative hemoglobin was 8.2 g/dL.

  • His vitals on admission at noon are:
  • heart rate 75 beats/min
  • blood pressure 120/68 mm Hg
  • respiratory rate 20 breaths/min
  • SpO2 100% on 4 L oxygen via nasal cannula

Over the next 12 hours, his abdominal drain produced 700 mL of sanguineous output and his urine output decreases from 80 mL/h in immediate postoperative period to 20, 10, and 5 mL, respectively, in the last 3 consecutive hours. His vitals 12 hours after admission are now:

  • heart rate 105 beats/min
  • blood pressure 85/50 mm Hg
  • respiratory rate 20 breaths/min
  • SpO2 100% on 2 L oxygen via nasal cannula

Which of the following would be LEAST likely in this patient? 

A. A serum BUN:Cr ratio of 10:1
B. Fractional excretion of sodium (FENa ) >3%
C. High urine specific gravity
D. RBC casts on urine microscopy

Category: Critical Care Medicine-Renal, Electrolyte and Acid Base Disorders--->Oliguria and Polyuria
Page: 1 of 2