The intrinsic beauty of human physiology >> Beauty of the ICU >> “Art” in the ICU >>(CO = HR x ??)

p1090783

“In a Nutshell” :  the beauty of human physiology

Although this is just a swishing and sloshing of stuff in the ICU, there is intricate beauty in this clip … just activate the “replay” function of the movie player your PC uses.

The urine output flow is demonstrated in the clear urine “moving along” in the urimeter set.

The blood sloshing around represents the collection moving around to the beat of the HR.

Between these 2 fluid volumes sloshing around, is the implied requisite stroke volume per heart beat.

 

2 min Evaluation – Urimeter = translucent red – 10 seconds to reach a conclusion

urmhbur
2 min Evaluation – Urimeter – 10 seconds to reach a conclusion

The quick explanation :

Situation :    urine = (translucent) red.

Background :    hemoglobinuria.  (I had originally identified this erroneously as methemoglobinemia – mea culpa),

Action :    requires alkalinization of urine to avoid acute renal failure.

Recommendation :     increase pH~7.50 (increase minute volume).

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The “long winded” explanation :

S-B-A-R format reporting – quick reporting format for handoff from one healthcare professional to another.

A lot of this presentation is conjecture … but time and experience has proven correct 99 out of 100 times.

Translucent red urine – the hemoglobin have been “beaten up” / ” chewed up” by some unknown process’ (the usual offending agent is heart surgery,
general surgery or rhabdomylosis.

RBCs (=bags of hemoglobin) have lost their membrane integrity and free floating hemoglobin
is now coursing thru the cardiovascular system.

As the hemoglobin pass thru the renal vascular anatomic structures, the hemoglobin molecularly binds with the distal convoluted tubule

(DCT) structures and causes acute renal failure (ARF-k).

The transient solution is to alkalinize the urine.

Alkalinization of urine will create an environment non-conducive to precipitation of free hemoglobin on renal DCT sub-structures. (further reading >> pH and molecular structure / shaping).

The free-floating hemoglobin tends to bind poorly to DCT structures in an alkalemic environment.

Transient solution is to increase the minute volume to target a pH~7.50.

2 min Evaluation – Urimeter – translucent green – 10 seconds to reach a conclusion

urmtlynbl
The quick explanation :

Situation :    urine = (translucent) green.

Background :    hypotension.

Action :    methylene blue intravenous injection.

Recommendation :     Alveolar recruitment technique (ART).

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The “long winded” explanation :

S-B-A-R format reporting – quick reporting format for handoff from one healthcare professional to another.

A lot of this presentation is conjecture … but time and experience has proven correct 99 out of 100 times.

Translucent green urine – refractory systemic vascular hypotension (from excessive nitric oxide in general systemic circulation) >  methylene blue dye irreversibly binds nitric oxide (NO) molecules – systemic blood pressure should increase status post  random scavenging.

The patient’s vascular system is producing excessive amounts of nitric oxide in endovascular epithelial tissue.
Last resort to refractory hypotension is to offer a free floating agent in the cardiovascular system to be reduced by nitric oxide
and thereby decrease the systemic vascular dilation (increased SVR) by “free range” nitric oxide.

Last resort because methylene blue is nephrotoxic.

 

Tricks of the trade – what your patient’s urine collection bag is telling you.

 

urcn02

yellow =  normal

uryll

darker yellow = concentrated urine (patient may be dehydrated)

urtrm

red (non-translucent) = traumatic catheter insertion / traumatized genitourinary (GU) system.

urmhbur

red (translucent) = hemoglobinurea (free hemoglobin in urine) >> may cause acute renal failure > keep patient mildly alkalemic to avoid free hemoglobin-distal convoluted tubule complexes from forming.

urmtlynbl

green / light blue – patient may be receiving MethleneBlue intravenously as “nitric oxide scavenger” therapy (MORE TO FOLLOW).  or after abdominal surgery (if JP drains drain from the abdomen, there is a vascular leak in the abdomen (MORE TO FOLLOW).

urlsx

near clear = likely a “forced” diuresis (ex. Lasix)

urbldirgn

red (from dark red > to light red > to clear) – likely, ongoing bladder irrigation as a washout of bladder.

urbldirgnii

2 bottles hanging  are infusing into the bladder – to be followed by release of bladder irrigant into urine collection bag.