What are the appropriate interventions for a patient in the Surgical Intensive Care Unit (SICU) with multiple rib fractures and impaired renal function, specifically oliguria (inability to urinate) since admission?

From the Guidelines

You should immediately assess the patient for urinary retention or acute kidney injury and consider placing a urinary catheter to relieve potential retention and monitor output, as indicated by the patient's lack of urination since admission and the presence of multiple rib fractures, which may require close monitoring of urine output in the ICU setting, as suggested by 1. When evaluating the patient, it's crucial to check for a distended bladder through physical examination or bedside ultrasound. If the bladder is distended, placing a urinary catheter can help relieve retention and monitor output. If the patient already has a catheter, checking for obstruction by flushing it gently is essential. Some key points to consider in the assessment and management include:

• Obtaining basic labs, including BUN, creatinine, and electrolytes, to evaluate kidney function, as the patient's lack of urination could indicate pre-renal azotemia from hypovolemia, intrinsic kidney injury from shock, or post-renal obstruction.
• Ensuring adequate fluid resuscitation while being cautious of volume overload in a patient with rib fractures who may be at risk for respiratory compromise, taking into account the principles of fluid management outlined in 1.
• Considering pain management optimization, as severe pain from rib fractures can lead to sympathetic activation and decreased urine output.
• Assessing for contributing factors such as hypotension, nephrotoxic medications, or rhabdomyolysis from trauma if the patient shows signs of acute kidney injury, and considering early nephrology consultation if initial interventions don't improve urine output or if lab values indicate significant kidney dysfunction.

From the FDA Drug Label

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From the Research

Assessment and Diagnosis

• The patient's inability to urinate since admission to the surgical ICU with multiple rib fractures requires immediate attention to prevent potential kidney damage or urosepsis 2, 3.
• A detailed history and focused physical examination with neurologic evaluation should be performed to identify potential causes of urinary retention 4.
• Diagnostic testing should include measurement of postvoid residual (PVR) volume of urine to determine the severity of urinary retention 4.

Treatment and Management

• Initial management of urinary retention involves assessment of urethral patency with prompt and complete bladder decompression by catheterization 4.
• Suprapubic catheters may be considered to improve patient comfort and decrease bacteriuria and the need for recatheterization in the short term 4.
• Further management will depend on determining the cause and chronicity of the urinary retention, and may include initiation of alpha blockers with voiding trials 4.
• Nurses play a key role in identifying patients at risk of acute urinary retention and in assessment and management of the condition 5.

Potential Causes

• Obstructive causes, such as benign prostatic hyperplasia, are common in men and may contribute to urinary retention 6, 4.
• Infectious, inflammatory, iatrogenic, and neurologic causes can also affect urinary retention 6, 4.
• The patient's multiple rib fractures may be a contributing factor to their urinary retention, and should be considered in the assessment and management of the condition.