GU Male MDT Flashcards
Hematuria visible to the naked eye
Gross Hematuria
Hematuria only detectible by examination of the urine sediment by microscopy, or urinalysis
Microscopic
Both gross and microscopic hematuria require:
Evaluation
An upper urinary tract source (kidneys and ureters) can be identified in __% of patients with gross or microscopic hematuria
10%
Hematuria
Stone disease accounts for __%
40%
Hematuria
__% caused by kidney disease
20%
Hematuria
__% from renal cell carcinoma
10%
Hematuria
__% caused by urothelial cell carcinoma of the ureter or renal pelvis
5%
The lower tract source of gross hematuria is most commonly from:
Urothelial carcinoma of the bladder
Microscopic hematuria in the male is most commonly from:
Benign prostatic hyperplasia
Gross hematuria
What may help localize the disease?
Description of timing
The presence of blood at the beginning of the urinary stream that clears during the stream, implies an anterior penile urethral source
Initial hematuria
The presence of the blood at the end of the urinary stream, implies a bladder neck or prostatic urethral source
Terminal hematuria
The presence of blood through the urinary stream, implies a bladder or upper tract source
Total hematuria
Hematuria associated with renal colic suggests:
Ureteral stone
Irritative voiding symptoms in a young woman may suggest:
Acute bacterial infection and associated cystitis
In the absence of other symptoms, gross hematuria may be more indicated of:
Tumor
Labs:
Hematuria
UA
Urine Culture
BUN and Creatinine
Imaging:
Hematuria
CT scan of the upper tract w/o contrast
Cystoscopy
Indicated in patients with gross hematuria or those over 35 years with asymptomatic hematuria
Cystoscopy
Treatment for hematuria
Depends on the underlying disease process
Hematuria UA
Proteinuria and casts suggest:
Renal Origin
What kind of bacteria are responsible for most of the UTIs?
Coliform bacteria (E. Coli)
Most common route for UTI
Ascending infection from the urethra
Infection of the bladder
Cystitis
Cystitis is most commonly caused by:
Coliform bacteria
-E. Coli
Gram-positive bacteria
-Enterococci
Uncomplicated cystitis in men is rare and suggests:
Infection from stones
Prostatitis
Chronic urinary retention
Signs and symptoms:
- Irritative voiding symptoms
- Suprapubic discomfort
- Women have hematuria after sex
- Usually afebrile
- Exam may elicit suprapubic tenderness with palpation
Cystitis
Noninfectious cystitis can be caused by:
Pelvic irradiation
Chemotherapy
Bladder carcinoma
Interstitial cystitis
Voiding dysfunction disorders
Psychosomatic disorders
Cystitis UA may reveal
Pyuria
Bacteriuria
Various degrees of hematuria
Treatment for cystitis
Antimicrobial therapy
- Ciprofloxacin
- Nitrofurantoin
- Trimethoprim/sulfamethoxazole (Bactrim)
Urinary analgesics
-Phenazopyridine
Women who have more than __ episodes of cystitis per year are considered candidates for prophylactic antibiotic therapy
3
The three most commonly used oral agents for Cystitis prophylaxis
Trimethoprim-sulfamethoxazole (40/200mg) daily
Nitrofurantoin (100mg) daily
Cephalexin (250mg) daily
Infectious inflammatory disease involving the kidney parenchyma and renal pelvis
Pyelonephritis
Most common causative agents that cause pyelonephritis
Gram-negative bacteria:
- Klebsiella
- Proteus
- E Coli
- Enterobacter
- Pseudomonas
Bacteria commonly seen in pyelonephritis
Gram-positive
- Enterococcus faecalis
- Staphylococcus
What bacteria causes Pyelonephritis from a hematogenous route?
Staph Aureus
Signs and symptoms
- Fever
- Flank pain
- Irritative voiding symptoms (urgency, frequency, dysuria)
- Shaking chills
- Associated nausea & vomiting
- Diarrhea
- Tachycardia
- Costovertebral angle tenderness is usually pronounced
Pyelonephritis
Pyelonephritis lab findings
CBC: Leukocytosis & Left Shift
UA: Pyuria, bacteriuria, hematuria, white cell casts
Urine Culture: Heavy growth of offending organism
Blood culture may be positive
Imaging for pyelonephritis
Renal Ultrasound
-May show hydronephrosis (stone/obstruction)
Treatment for pyelonephritis
Antibiotic therapy (2-week therapy)
- Ampicillin & Gentamicin IV
- Ciprofloxacin PO
- Levofloxacin PO
- Trimethoprim-sulfamethoxazole PO
Urinary Analgesics
-Phenazopyridine
Pyelonephritis
IV antibiotics are continued for __ hours after the fever resolves and oral antibiotics are then given to complete the 14 day course of therapy
24 hours
Pyelonephritis
Fevers may persist for up to __ hours even with appropriate antibiotics
72
Inflammation and infection of the prostate gland
Acute Prostatitis
Prostatitis is usually caused by:
Gram negative
- E Coli
- Pseudomonas Species
Prostatitis is less commonly caused by:
Gram-positive
-Enterococci
Most likely routes for infection of prostatitis
Ascent up the urethra
Reflux of infected urine into the prostatic ducts
(Lymphatic and hematogenous routes are rare)
Signs and symptoms
- Perineal, sacral, or suprapubic pain
- High fever
- Irritative voiding symptoms
- Obstructive symptoms, urinary retention
- Warm and often exquisitely tender prostate (gentle exam)
Prostatitis
Laboratory findings in prostatitis
CBC: Leukocytosis and left shift
UA: Pyuria, bacteriuria, hematuria
Treatment for prostatitis
Antibiotics (4-6 weeks)
- Ampicillin & Gentamicin IV
- Ciprofloxacin PO
- Levofloxacin PO
- Trimethoprim-sulfamethoxazole PO
Tylenol
NSAIDs
Stool softeners
Prostatitis
IV Antibiotics are continued for ___ hours after the fever resolves and oral antibiotics are given to complete the ___ week course therapy
24-48 hours
4-6 weeks
May evolve from acute bacterial prostatitis
Many men have no history of acute infection
Chronic bacterial prostatitis
What organism is associated with chronic bacterial prostatitis infection?
Gram Neg Rods (MOST COMMON)
Enterococcus (Gram Positive)
Prostate may be:
Normal
Boggy
Indurate
Chronic bacterial prostatitis
Pelvic radiographs or transrectal U/S may show:
Prostatitis calculi
Treatment for Chronic bacterial prostatitis
Antimicrobials (6-12 weeks Therapy)
- Trimethoprim-sulfamethoxazole PO
- Ciprofloxacin PO
- Levofloxacin PO
NSAIDs
Sitz Baths
Chronic bacterial prostatitis optimal duration of antibiotic therapy length
6-12 weeks
Inflammation and/or infection of the epididymis
Epididymitis
Sexually transmitted forms of epididymitis usually occur in men under:
40
Sexually transmitted epididymitis is caused by:
Chlamydia trachomatis
Neisseria gonorrhoeae
Non-sexually transmitted forms of epididymitis occur in:
Older men
Associated with UTI and Prostatitis
Non-sexually transmitted epididymitis is typically caused by:
Gram-negative rods
- E coli
- Klebsiella
Signs and symptoms
- May follow acute physical strain, trauma, or sex
- Associated Sx: Urethritis, Cystitis
- Pain in the scrotum, may radiate to flank
- Fever
- Scrotal swelling
Epididymitis
Physical findings
Early course of epididymitis:
The epididymis may be distinguishable from the testes
Later course of epididymitis
The teste and epididymis appear as one enlarged tender mass
Elevation of the scrotum above the pubic symphysis improves pain from epididymitis
Prehn sign
Epididymitis
Testing for suspected chlamydia and gonorrhoeae
NAAT (Nucleic acid amplification testing)
Imaging for epididymitis
Ultrasound
Treatment for sexually transmitted epididymitis
Ceftriaxone IM & Doxycycline PO
Treatment for non-sexually transmitted epididymitis
Trimethoprim/sulfamethoxazole
Ciprofloxacin
Levofloxacin
Complications of epididymitis that is delayed or inadequate treatment may result in:
Epididymo-orchitis (Testicle Inflammation)
Decreased fertility
Abscess formation
Epididymitis
Refer to urology when:
Persistent symptoms and infection despite antibiotic therapy
Signs of sepsis or abscess formation
Renal calculi is also known as:
Urolithiasis
Men are more effected by urolithiasis than women by:
2.5:1
How many major types of urinary stones are there?
5
Most common type of urinary stone
Calcium (85%)
Weather
Contributing factors of renal calculi
High humidity & elevated temperatures
Higher incidence rates of renal calculi are associated with what disease processes?
Sedentary lifestyle
Hypertension
Carotid calcification
Cardiovascular disease
Diet that is associated with renal calculi
High protein and salt intake
Inadequate hydration
Signs and symptoms:
- Pain often occurs suddenly in the flank
- Nausea and vomiting
- Constantly moving to find a comfortable position
- May be episodic
Renal calculi
Urinalysis findings in renal calculi
Hematuria (90%)
Urinary pH
Imaging for Renal Calculi
Plain abdominal radiograph (Kidney, Ureter and Bladder)
Renal U/S
Spiral CT in prone position
Renal calculi
KUB with renal U/S can diagnose up to __% of stones
80%
Renal calculi
What has increased sensitivity and specificity over other tests?
Spiral CT
Stones smaller than ____mm in diameter on a plain abdominal radiograph usually pass spontaneously
5-6 mm
Renal Calculi
Medications that can increase the rate on spontaneous stone passage
Alpha-blockers (Tamsulosin)
NSAIDs
-With or without a low dose oral corticosteroid
Stones that require surgical removal include those that are showing signs of:
Obstruction or infection
Procedures for stone removal include:
Ureteroscopy stone extraction
Extracorporeal shock wave lithotripsy
The greatest importance in reducing stone recurrence
Increased fluid intake
Renal calculi
Increasing fluid intake to ensure a voided volume of:
2.5 L/day
Stones
Patients are encouraged to ingest fluids during meals, __ hours after each meals, and prior to sleep
2 hours
Renal calculi
Sodium intake should be restricted to:
150 mEq/day
Renal calculi
Protein intake should be:
Spread out through the day
Limited to 1g/kg/day
Disposition
Obstructing stone with associated infection is a:
MEDEVAC
Renal calculi
Signs/symptoms of infection:
Fever
Tachycardia
Elevated WBC
Referral to urology is warranted if the stone fails to pass within:
4 weeks
Two types of erectile tissue
Corpus cavernosa
Corpus spongiosum
Normal male erection is a neurovascular event relying on:
Intact autonomic and somatic nerve supply
Arterial blood flow
Smooth and striated musculature of the corpora cavernosa and pelvic floor
Erection is caused and maintained by:
Increase in arterial flow
Relaxation of the smooth muscle
Increase in venous resistance
The key transmitter that initiates and sustains erections
Nitric oxide
The consistent inability to attain or maintain a sufficiently rigid penile erection for sexual performance
Erectile dysfunction (ED)
ED has what kind of etiologies?
Organic and psychogenic
Organic erectile dysfunction may be an early sign of:
Cardiovascular disease
Loss of libido may indicate:
Androgen deficiency
Loss of erections may result from:
Arterial
Venous
Neurogenic
Hormonal
Psychogenic
The most common cause of erectile dysfunction is:
Decrease in arterial flow resultant from progressive vascular disease
The ability to attain but not maintain an erection may be the first sign of:
Endothelial dysfunction and further Cardiovascular risk
What medications are associated with erectile dysfunction?
Antihypertensive
Antidepressant
Opioids
Fibrotic disorder of the tunica albuginea of the penis resulting in varying degrees of penile pain, curvature, or deformity
Peyronie disease
The loss of seminal emission
Anejaculation
Anejaculation may result from
Androgen deficiency
Sympathetic denervation as a result of spinal cord injury
Labs for erectile dysfunction:
Lipid profile (dyslipidemia)
Glucose (diabetes)
Testosterone
Free testosterone must be drawn at what hours?
8-10 am
Treatment for ED:
Lifestyle modification (smoking, alcohol, diet, exercise)
Hormonal replacement
Oral agents (phosophodiesterase-5 inhibitors)
ED
Men with psychogenic component benefit from:
Sexual health therapy or counseling
Occurrence of penile erection lasting longer than 4 hours
Priapism
Ischemic injury of the corpora cavernosa from venous congestion and cessation of arterial inflow
Priapism
Initial treatment for priapism
Aspiration of blood from the penis and injection of sympathomimetic drugs (epinephrine/phenylephrine)
Benign prostatic hyperplasia (BPH) is a hyperplastic process, meaning:
There is an increased number of cells
Most common benign tumor in men and its incidence is age related
BPH
At age 55, __% of men report obstructive voiding symptoms
25%
At age __, 50% of men report decrease in the force and caliber of the urinary stream
75
BPH symptoms can be related to what two things?
1) OBSTRUCTIVE component of the prostate
2) IRRITATIVE, secondary response of the bladder to the outlet resistance
Hesitancy
Decreased force and caliber of stream
Sensation of incomplete bladder empyting
Double voiding (urinating 2 times within 2 hours)
Straining to urinate
Postvoid dribbling
Obstructive BPH symptoms
Urgency
Frequency
Nocturia
Irritative BPH Symptoms
Most important tool used in the evaluation of patients with BPH
American Urological Association (AUA) symptom index
AUA symptom index
Number of questions & scale
7 questions
Severity of 0-5
BPH DRE exam normal findings
Smooth firm elastic enlargement of the prostate
DRE findings that should alert you for possible prostate cancer
Induration
Labs for BPH
UA: to exclude infection/hematuria
Prostate specific antigen test (PSA)
BPH
Only recommended to assist in determining the surgical approach
Cystoscopy
BPH
CT or renal Ultrasound is recommended only:
Concomitant urinary tract disease or complications
Treatment for BPH patients with mild symptoms
Watchful waiting
Medical therapy for BPH
Alpha-blockers
5-alpha-reductase-inhibitors
Phsophdiesterase-5 inhibitors
Act against bladder outlet obstruction by relaxing smooth muscle in the bladder neck, prostate capsule, and prostatic urethra
Alpha-blockers
Act by reducing the size of the prostate gland and in turn improves symptoms
5-alpha-reductase inhibitors
Used in patients with erectile dysfunction with mild or moderate symptoms
Phosphdiesterase-5 inhibitors
BPH
Absolute surgical indications:
Refractory urinary retention (failing one catheter removal)
Large bladder diverticula
Sequelae of benign prostatic hyperplasia
Conventional surgeries for BPH
Transurethral resection of the prostate (TURP)
Transurethral incision of the prostate (TUIP)
Open simple prostatectomy
Minimally invasive surgeries for BPH
Laser therapy
Transurethral needle ablation of the prostate (TUNA)
Transurethral elect vaporization of the prostate
Hyperthermia
Implant, to open prostatic urethra
Refer to urology with an AUA score of:
> 7
Most common non-cutaneous cancer in American men and second leading cause of cancer related death in men
Prostate Cancer
A 50 year old American man has a lifetime risk of:
__% latent cancer
__% clinically apparent cancer
__% death due to prostatic cancer
40%
16%
2.9%
Risk factors of prostate cancer
African American race
Family history
History of high dietary fat intake
Most prostate cancers are detected because of:
Elevations in serum PSA
Obstructive symptoms of the prostate is most often due to:
BPH
Prostate cancer
Metastases commonly occurs in:
Lower extremity lymphedema
Axial skeleton (Most Common)
__% if men with intermediate elevation between 4.1-10 ng/mL will have prostate cancer
__% of men with elevations greater than 10 ng/mL will have prostate cancer
8-30%
50-70%
Labs for prostate cancer
PSA
BUN & Creatinine
Alkaline phosphatase and calcium
CBC
Standard method for detection and confirmation of prostate cancer
Prostate biopsy
Imaging for prostate cancer
Transrectal U/S
MRI
Bone Scan
PSA testing baseline testing is offered at what age with no risk factors?
50
PSA testing for 40-45 year old’s with risk factors that include:
African American men
Family history of prostate cancer
BRCA1 or BRCA2 mutations
Prostate cancer possible therapies
Active surveillance
Radical prostatectomy
Radiation therapy
Cryosurgery
Androgen deprivation therapy for advanced disease
All patients with a focal nodule or induration on DRE or elevated PSA MUST be:
Referred to Urology
What is responsible for the infrequent rate of injury to the testis?
Mobility of the testicle
Cremasteric muscle
Tough capsule of the testes
What is a part of the spermatic cord?
Vas deferens
Cremasteric muscle
Artery
Vein
Nerves
Scrotal laceration/avulsion should be:
Explored and debrided
Managed by housing the testicle in the remaining scrotal skin
Blunt testicular injury usually occurs secondary to a direct blow to the testes impinging against the:
Pubic symphysis (Bicycle injury)
Sac fills with blood and appears as a large blue tender scrotal mass
Blunt testicular injury
Labs for testicular trauma
CBC
UA
Imaging for scrotal trauma
Scrotal and testicular US
What studies can help delineate the extent of testicular involvement and evaluate for testicular rupture?
Colored Doppler
Blunt and penetrating testicular injuries require:
MEDEVAC to Urology
Treatment for lacerations or avulsions just involving the skin of the scrotum
Closed primarily by independent provider
Necrotizing fasciitis of the subcutaneous tissues of the perineum often involving the scrotum
Fournier’s Gangrene
Typically begins as a benign infection or simple abscess that quickly leading to widespread necrosis of otherwise previously healthy tissue
Fournier’s Gangrene
You must maintain a high suspicion of what, if the patient presents with scrotal, rectal or any genitalia pain out of proportion to their physical exam findings
Fournier’s Gangrene
Signs and symptoms:
- Tense edema of scrotum and other involved skin
- Blisters/bullae
- Crepitus
- Fever
- Pain out of proportion to physical exam
- Tachycardia
- Hypotension
Fournier’s Gangrene
Imaging for Fournier’s Gangrene
CT
MRI
Treatment for Fournier’s Gangrene
Aggressive surgical exploration and debridement
Broad spectrum antibiotics
-Ertapenem
Fluids
MEDEVAC
Complications from Fournier’s gangrene.
Patients may ultimately need:
Cystostomy
Colostomy
Orchiectomy
Malignancy is often:
Painless
Dilation of the pampiniform plexus of spermatic veins and is generally left sided
Varicocele
Symptoms:
- Asymptomatic mass, may have mild pain
- Mass is separate from testes
- Feels like a “bag of worms”, especially upright
- Size increased with Valsalva
Varicocele
Right sided varicocele should raise suspicion of:
Inferior vena cava and intraabdominal pathology
Sudden left sided varicocele should raise suspicion for:
Left renal vein obstruction
Renal tumor
Collection of peritoneal fluid between the parietal and visceral layers around the testes and spermatic cord
Hydrocele
Gradually enlarging painless cystic mass that transilluminates
May indicate tumor
Hydrocele
Fluid filled cyst at the head of the epididymis that may contain nonviable sperm
Spermatocele
Painless
Palpated as distinct from the testes
Typically transilluminates as cystic in nature
Spermatocele
Diagnostic imaging of choice for scrotal and testicular abnormalities
Ultrasound
Most common neoplasm in men aged 20-35
Testicular cancer
Testicular cancer
What is necessary for diagnosis?
Orchiectomy
Testicular cancer
___ cases per 100,00 males each year
5-6
__% of testicular cancer develop in patients with a history of cryptorchism
5%
Symptoms:
- Painless enlargement of the testis
- Sensation of heaviness
Testicular cancer
Testicular cancer
__% Asymptomatic
__% Metastatic disease symptoms
__% Gynecomastia
10%
10%
5%
An incorrect diagnosis is made at the initial examination in up to __% of patients with testicular tumors
25%
If this test is positive, you should have a high suspicion of testicular cancer
HCG
Imaging for testicular cancer
Scrotal US
-Determine intra/exta-testicular
Chest, abd, and pelvic CT after diagnosis is made
__% of testicular cancer diagnosis is made by inguinal orchiectomy
75%
Testicular cancer
5-year disease free survival for patients with stage I-III are ___%
90-100%
Testicular Cancer
Patients with disseminated disease have a 5-year disease free survival rate at __%
55-80%
Testicular torsion may occur after:
Trauma
Spontaneously
Urgency to diagnose and treat testicular torsion with __ hours to prevent loss of the testis
6 hours
Testicular torsion tends to occur in:
Young men
Which testicle is more prone to torsion?
Left
Testicular torsions usually rotate:
Medially
Symptoms:
- Acute scrotal pain (several hours after activity)
- Profound tenderness and swelling
- Nausea and vomiting
- Negative cremasteric reflex
Testicular torsion
High riding testis oriented transversely
Bell clapper deformity
Imaging for testicular torsion
Scrotal US with color flow Doppler
Manual Detorsion
Grasping the testicle and rotating it within the scrotum outward (Lateral to Medial) one to two full 360 degree turns
If there is no improvement from testicle detorsion you should:
Rotate it in the opposite direction (lateral to medial)
_____ of torsed testicles may have lateral rotation
One-third
Disposition for testicle torsion
MEDEVAC
Needs surgical exploration and detorsion regardless of result of manual detorsion
Testicle salvage
___% at 6-8 hours
___% at 12 hours
80-100%
0%
___% of patients sustaining injury to the external genitalia require RBC transfusion due to blood loss from genital injury alone
25%
Blunt trauma to the erect penis may cause rupture of the:
Corpus cavernosum
- Immediate pain
- Deforming hematoma (eggplant)
- “Cracking sound”
- Immediate detumescence
- May cause urethral injury
Penile rupture or fracture
Can occur secondary to clothing being trapped by heavy machinery
Amputation
Treatment zipper injuries
Local anesthetic is injected and then unzip after mineral oil lubrication
Treatment for penile contusions
Analgesics/NSAIDs
Cold packs
Rest
Elevation
Imaging for penile trauma
Retrograde urethrogram
Scrotal/Penile US
Treatment for penile trauma
MEDEVAC
Immediate urological consultation for surgical repair
Urethral injury is suspected if:
Blood in the urethra meatus
Perineal hematoma
High riding prostate on DRE
Fibrous constriction of the foreskin preventing retraction
Phimosis
Inflammation of the glans penis
Balanitis
Inflammation of the glans penis and the prepuce
Balanoposthitis
If Foley catheter cannot be inserted, what is indicated?
Suprapubic catheterization
Most common infectious cause of underlying balanoposthitis
Candidal infection
Treatment for Phimosis
Good hygiene and topical antifungal
Phimosis
Urologist can perform this procedure to temporarily fix the problem
Dorsal slit circumcision
Two conditions that can be the result from phimosis
Balanitis
Balanoposthitis
A true urologic emergency
Retracted foreskin develops a fixed constriction proximal to the glans
Paraphismosis
Treatment for paraphimosis
Manual reduction
-Compress glans firmly for 5-10 minutes to reduce its size
-Icing
Move the prepuce distally while the glans is pushed proximally
Treatment
Manual reduction fails for paraphimosis
Dorsal slit of the foreskin
Disposition
Paraphismosis
Referral to urology for circumcision to reduce recurrence
Results in a sudden decrease in kidney function
Acute Kidney Injury (AKI)
Labs
AKI is characterized as:
Increase in serum creatinine
The inability to maintain acid-base, fluid, and electrolyte balance and to excrete nitrogenous wastes
AKI
Three categories of AKI
Prerenal
Intrinsic
Post renal
Most common etiology of AKI
Prerenal (40-80%)
Prerenal AKI
Continuous hypoperfusion can lead to:
A secondary intrinsic kidney injury
Decreased renal perfusion occurs by:
Decrease in intravascular volume
Change in vascular resistance
Low cardiac output
Least common cause (5-10%) of AKI
Postrenal
Postrenal AKI
Important to detect because etiologies are:
Reversible
Postrenal causes
Urethral obstruction
Bladder dysfunction or obstruction
Obstruction of both ureters/renal pelvises
BPH
Cancer (Bladder, prostate, and cervical)
Most common cause of postrenal AKI in males
BPH
Up to 50% of AKI
Intrinsic
Consider intrinsic AKI after:
Prerenal and postrenal causes are ruled out
Sites of intrinsic AKI injury
Tubules
Interstitium
Vasculature
Glomeruli
Symptoms:
- Buildup of waste products (nausea, vomiting, altered sensorium, pericarditis, malaise)
- Pericardial effusion leading to tamponade and friction rub
- Arrythmias
- Rales in hypervolemia
- Diffuse abdominal pain and ileus
Acute Kidney Injury
Labs for AKI
Blood Urea Nitrogen (BUN)
Creatinine
UA
AKI
Can help determine prerenal, postrenal or intrinsic
Creatinine (Cr)
Imaging for AKI
Renal US
Treatment for prerenal AKI
Achieving euvolemia
Restoring renal perfusion
Treatment for postrenal AKI
Bladder catheterization
Relieve underlying cause
Treatment for AKI
Usually self-limited
Managed by nephrology
Complications of AKI
Dialysis
Arrhythmias secondary to electrolyte abnormalities
Bleeding/clotting disorders
Encephalopathy
Cardiac Tamponade
Disposition for AKI
MEDEVAC
Prerenal: ER, Cardiology, Internal Medicine
Postrenal: Urology referral to relieve obstruction
Intrinsic: Nephrologist
Hyponatremia is defined as:
Less than 135 mEq/L
Most common electrolyte abnormality in hospitalized patients often caused by hypotonic fluids
Hyponatremia
Hyponatremia is usually caused by:
Excess water-retention
Mismanagement of hyponatremia can result in:
Neurologic catastrophes from cerebral osmotic demyelination
Evaluation for hyponatremia
New medications
Changes in fluid intake
Fluid output
Mild hyponatremia
130-135 mEq/L
Nausea
Malaise
Moderate hyponatremia symptoms
Headache
Lethargy
Disorientation
Severe symptoms of hyponatremia
Respiratory arrest
Seizure
Coma
Permanent brain damage
Brainstem herniation
Death
Treatment for hyponatremia
Restriction of free water and hypotonic fluid
Less than 1-1.5 L/day
Hyponatremia
What may be necessary in patients with negative free water clearance?
Hypertonic saline
Most serious complication of hyponatremia is iatrogenic cerebral osmotic demyelination from:
Overly rapid sodium correction
Symptomatic and severe hyponatremia generally require:
Hospitalization for
- Monitoring of fluid balance and weights
- Treatment
- Frequent sodium checks
Hypernatremia is classified as:
Sodium concentration greater than 145 mEq/L
Hypernatremia is typically due to:
Free water loss
Primary defense against hypernatremia
Intact thirst mechanism and access to water
Signs and symptoms:
- Dehydration (hypotension, oliguria)
- Lethargy
- Irritability
- Weakness
Hypernatremia
Severe signs of Hypernatremia (>158)
Hyperthermia
Delirium
Seizures
Coma
Treatment for hypernatremia
Correcting the cause of fluid loss
Replacing water
Replacing electrolytes
Hypernatremia
Fluids should be administered over a _____ period
48-hour
Hypernatremia
Aiming for serum sodium correction of approximately
1 mEq/L/h
Rapid correction of hypernatremia may cause:
Cerebral edema
Severe neurologic impairment
Hypokalemia is classified as:
<3.5 mEq/L
Severe hypokalemia may induce:
Arrhythmias and rhabdomyolysis
Hypokalemia can result from:
Insufficient dietary potassium intake
Intracellular shifting
The most common cause of hypokalemia is:
GI loss from infectious diarrhea
The potassium concentration in intestinal-secretion is __ times higher than in gastric secretions
10 times
Symptoms
Mild to moderate hypokalemia
Muscular weakness
Fatigue
Muscle cramps
Severe hypokalemia
<2.5mEq/L
Signs and symptoms of severe hypokalemia
Flaccid paralysis
Hyporeflexia
Hypercapnia
Tetany
Rhabdomyolysis
Imaging for hypokalemia
ECG
- Decreased and broadening of T waves
- PVCs
- Depressed ST segments
Treatment for hypokalemia
Oral potassium supplementation
-40-100 mEq/day for days to weeks
Complications of hypokalemia
Cardiac arrhythmias
Rhabdomyolysis
Hyperkalemia
> 5.0 mEq/L
Hyperkalemia may develop in patients taking:
ACE inhibitors
Angiotensin-receptor blockers
Potassium-sparing diuretics
Hyperkalemia usually occurs in patients with:
Advanced kidney disease
Hyperkalemia
_____ causes intracellular potassium to shift extracellularly
Acidosis
Hyperkalemia impairs neuromuscular transmission, causing:
Muscle weakness
Flaccid paralysis
Ileus
Can causing a raise in potassium concentration by 1-2 mEq/L by causing acidosis and potassium shift from cells
Fist clenching during venipuncture
ECG changes in hyperkalemia include
Bradycardia
PR interval prolongation
Peaked T waves
QRS widening
Conduction disturbances (bundle branch block, AV block)
V-Fib and cardiac arrest
Treatment for hyperkalemia
Withholding exogenous potassium
Hyperkalemia
Emergent treatment is indicated when:
Cardiac toxicity
Muscle paralysis
Severe hyperkalemia (>6.5)
Shifts potassium intracellularly within minutes of administration
Insulin (give with glucose)
Bicarbonate
Beta-agonists
Intravenous _____ may be given to antagonize the cell membrane effects of potassium
Calcium
Medications for hyperkalemia
Loop diuretics
- Furosemide
- Bumetanide
Complications of hyperkalemia
V-fib
Cardiac arrest
Epididymitis
Inflammation of the epididymis