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Anesthesiology > 12. AKI, liver failure, thyrotoxic crisis > Flashcards

12. AKI, liver failure, thyrotoxic crisis Flashcards

1
Q

Components of homeostasis

A
  • Volume status
  • Ions
  • Osmotic pressure
  • Water balance
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2
Q

Total water content adult

A

60 % of body

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3
Q

Intracellular fluid adult

A

40 % of body

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4
Q

Extracellular fluid adult

A

20 % of body

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5
Q

Intravascular space

A

5 % of body

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6
Q

Interstitial fluid

A

15 % of body

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7
Q

Third spaces

A

Secretory fluids

- saliva, digestive, edema etc

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8
Q

Fixed water excretions

A
  • Stool 0,1 L/d
  • Sweat 0,1 L/d
  • Pulmonary 0,3 L/d
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9
Q

Variable water excretion

A

Urine output (1,0-1,5 L/d)

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10
Q

Pathological fluid loss examples

A
  • Fever (1500 ml)
  • Extreme fever/extremely warm weather - 2000 ml
  • Tracheostomy - 700 ml
  • Bronchial toilette - 500-1000 ml
  • Hyperventilation - 500-1000 ml
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11
Q

Daily fluid need

A

30 ml/kg of adults

Children

  • 100 ml/first 10 kg
  • 50 ml/next 10 kg
  • 20 ml/additional kg
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12
Q

Intake fluids

A
  • Drink
  • Food
  • Oxidation water
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13
Q

Output water

A
  • Urine
  • Stool
  • Perspiration
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14
Q

Regulation of isotony

A
  • Kidneys

- Thirst

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15
Q

Normal daily electrolyte needs/tskg

A

Ca: 0,1 mmol
Mg: 0,1 mmol

K: 1,0 mmol
Cl: 1,0 mmol
Na: 1,0-2,0 mmol

Phosphate: 0,4 mmol

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16
Q

Daily proteinn need per day

A

1 g/kg body weight

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17
Q

Water and energy need per day

A

Water: 30 ml/kg body weight

Energy 30 kcal/kg body weight

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18
Q

Physiology of kidney

A
  • Ultrafiltration (0-8 nm)
  • Dialysis (visceral glomeral epithel)
  • Filtrate is protein-free plasm
  • Prox. Tubule reabs: 87 %
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19
Q

Renal circulation % of cardiac output

A

25 %

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20
Q

Vasoconstriction in kidney mediators

A
  • Cathecholamines (afferent)
  • ATII (efferent)
  • PGs (cortical up, medullary down)
  • Vegetative nerves, vasomotor centre
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21
Q

Vasodilation in. Kidney mediators

A
  • Acetylcholine

- Supine position

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22
Q

Autoregulation of renal circulation

A
  • Smooth muscle stretching pf afferent arteriole cause vasoconstriction
  • Low systemic BP increase ATII production + efferent a. Constriction
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23
Q

Clearance formula

A

(Urine conc of X x Amount of urine) / Plasma conc of X

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24
Q

Clearance tests

A
  • Inuline

- Creatinine

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25
Q

Normal GFR

A

125 ml/min

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26
Q

Factors influencing GFR

A
  • Blood flow
  • Hydrostatic pressures
  • Blood protein conc
  • Membrane permeability
  • Glomerulo-capillary surface are (can be reduced after nephrectomy or by glomerular diseases)
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27
Q

Types of tubular transports

A
  • Endocytosis (proteins)
  • Passive diffusion
  • Active transport
  • Facilitated diffusion
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28
Q

Consequences off impaired kidney function

A
  • Proteinuria (albumin)
  • Loss of conc/dilution
  • Uremia
  • Acidosis (acid retention)
  • Sodium retention (loss of Na excretion, hyperaldosteronism)
  • Water retention
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29
Q

Clinical signs of AKI

A
  • Azotemia (incr BUN, creatinine and uric acid)

- Uremia (=azotemia + clinical signs)

30
Q

Uremia AKI

A

Azotemia + clinical signs:

  • Nausea
  • Confusion
  • Acidosis, Kussmaul breathing
  • Edema
  • Infections
  • Electrolyte disturbances
31
Q

Risk factors of AKI

A
  • Chronic kidney insuff (acute-on-chronic)
  • Hypoxemia
  • Volume depletion
  • Urine infections
  • Diabetes, old, congestive HF, post-op
32
Q

AKI prerenal causes

A

60-80 %

  • Decreased CO
  • Volume-redistribution
  • Fluid depletion
33
Q

AKI renal causes

A

15-25 %

  • Nephrotoxic agents
  • Ischemia
  • Glomerular diseases
  • Interstitial nephritis
  • Infection-associated nephropathies
34
Q

AKI postrenal causes

A

9-12 %

  • Infections
  • Oncology
  • Vascular (e.g aneurysm)
  • Papillar necrosis (DM, analgetics)
  • Tubular (urate, methotrexate)
  • Miscellaneous (stones, ligature, blocked bladder catheter)
35
Q

RIFLE

A

AKI classification

  • Risk
  • Injury
  • Failure
  • Loss (Persistant ARF over 4 weeks)
  • ESRD (end-stage renal disease)
  • Consider GFR, creatinine and urine output
36
Q

AKI - Risk (RIFLE)

A
  • Creatinine x 1,5
  • GFR decr over 25 %
  • Urine output less than 0,5 ml/kg for 6 hr
37
Q

AKI - Injury (RIFLE)

A
  • Creatinine x 2
  • GFR decr over 50 %
  • Urine output less than 0,5 ml/kg for 12 hrs
38
Q

AKI - Failure (RIFLE)

A
  • Creatinine x 3
  • GFR decr over 75 %
  • Urine output less than 0,3 ml/kg for 12 hr
39
Q

AKIN criteria (2012)

A

Any of:
- Creatinine increase over 0,3 mg/dl
OR
- Creatinine increase from basal value x 1,5 in last week
OR
- Urine output less than 0,5 ml/kg/hr for 6 hrs

40
Q

Early biomarkers of AKI

A
  • NGAL (!)
  • Cystatin-C, KIM-1, IL18
  • TIMP-2
  • IGFBP-7)
41
Q

Conservative antiuremic treatment

A
  • Fluid restriction + diuretics
  • Electrolyte control
  • Protein intake (0,2-0,3 g/kg)
  • Acid-base homeostasis
  • Enhance renal perfusion (MAP, dopamine?)
42
Q

Carboanhydrase blocker diuretics

A

Azetalzolamide

  • Prox. Tubule
  • Clinical use: metabolic alkalosis, glaucoma, decrease fluid secretion
43
Q

Loop diuretics

A

Furosemide, etacrinic acid

44
Q

Loop duretics SEs

A
  • Hypochloremia
  • Hypokalemia
  • Hypomagnesemia
  • RBF increase
  • Ototoxic
  • Block pancreas (hyperglycemia)
  • Dyslipidemia
    Cave: anuria
45
Q

Thiazide diuretics

A

Hydrochlorthiazide, chlortalidone, clopamide

  • Distal tubule
  • Clinical use: GFR over 30 ml/min
46
Q

Potassium-sparing diuretics

A

Spironolactone, ailoride, triamterene

  • Aldosterone antagonists
  • Na block
47
Q

Triamterene SE

A

Megaloblastic anemia

48
Q

Osmotic diuretics

A

Glycerine, mannitol

  • SE: cardiac decompensation, high serum osmolarity (mannitol)
  • Don´t give in ARF (tubular necrosis)
49
Q

Renal replacement therapies (RRTs)

A
  • Hemofiltration
  • Hemodialysis
  • Hemodiafiltration
  • Plasmapheresis
  • Hemoperfusion
  • MARSH
50
Q

Indications of RRT

A
  • Oligo-anuria
  • Metabolic acidosis
  • Azotemia (BUN)
  • Hyperkalemmia
  • Dysnatremia
  • Magnesium over 4 mmol/l or lack of deep tendon reflexes
  • Uremic organ dysfunction
  • Diuretics resistant organ edema and AKI
  • Coagulopathies with polytransfusion
51
Q

Hemofiltration

A
  • Based on hydrostatic pressure difference

- Filtration influenced by filtration pressure and oncotic pressure

52
Q

Stopping RRT

A
  • Cease of indication criteria
  • Urine output over 1 ml/kg/hr for 24 hrs
  • Fluid balance can be kept without RRT
  • RRT complication
53
Q

Hemoperfusion

A
  • Absorption of blood solved toxins
  • Active carbon, resine
  • FLuid substitution not necessary
  • Can remove: many medicines and poisons
54
Q

Plasmapheresis

A
  • Separation of plasma from blood
  • Fresh plasma replacement to circulation
  • Can remove huge molecules and bound complexes!
55
Q

Types of phereses

A
  • Centrifugal separator

- Continous membrane separator

56
Q

Indications plasmapheresis examples

A
  • Guillain-Barré SY, Myasthenia gravis
  • Hyperviscosity, TTP/HUS/HELLP
  • Goodpasture syndrome
57
Q

Hepatic failure criteria (labs)

A
  • SeBi over 34 mmol/l (48 hrs)
  • SGOT (AST) 2x normal value
  • Se Albumine decrease
  • Se cholesterine decrease
58
Q

Hepatic failure - organ dysfunction

A
  • Hepato-renal syndrome
  • Hepatic coma
  • Hepato-pulmonal SY
  • Secondary hyperaldosteronism
59
Q

Most common causes of hepatic failure

A
  • Acetaminophen
  • Hepatitis B
  • Drug
  • Hepatitis A
60
Q

Clinical signs hepatic failure

A
  • Confusion, coma
  • Jaundice
  • Tachycardia, low BP
  • Small, shrunken liver
  • Ascites
  • Peripheral edema, warm extremities
61
Q

Prognosis of hepatic failure

A

Child-Pugh, consideres:

  • Encephalopathy
  • Ascites
  • INR
  • Albumine
  • Bilirubin
  • Each parameter gets 1-3 point, higher points increases mortality
62
Q

MELD

A

Model for End-stage Liver Diasease score (for transplantation
- COnsideres bilirubin, INR and creatinine

63
Q

Evaluation of hepatic failure (labs)

A
  • GOT, GTP (liver cell cytosol-destruction, low in cirrhosis)
  • ALP (cholestasis)
  • Coagulation tests (not vWF!!, tests PT and factor VII)
  • Albumin
64
Q

Clinical signs of hepatic encephalopathy

A
  • Seizures
  • Arching neck
  • Dilated pupils, sluggish or no response
  • Pronation of hands
  • Hyperextended extremities
65
Q

Cardiovascular effects of hepatic failure

A
  • Cardiomyopathy
  • Hyperdynamic circulation
  • Microcirculatory disturbances
  • Portal HT
  • Anemia, thrombopenia (hypersplenia)
66
Q

Hepato-pulmonal syndrome

A
  • Restrictive lung disease
  • Decreased contact-time in lung
  • Absence of hypoxic vasoconstriction in lung
  • Pulmonal HT
  • Porto-pulmonal HT (over 25 mmHg)
67
Q

Hepato-renal syndrome

A
  • Concomittant kidney injury
  • Enhanced RAAS activity
  • Secondaru ADH activation
  • TXA and endothelin activation
68
Q

Thyreotoxic crisis

A

Acute , life-treathening form of thyreotoxicosis

69
Q

Precipitating factors of thyreotoxic crisis

A
  • Infection
  • Trauma or manipulation by surgery
  • Non-thyroid operations
  • Pregnancy, pre-eclampsia
  • Drugs: amiodarone, iodine contrast, thyroxine overdose
70
Q

Signs and symptoms thyreotoxic crisis

A
  • Weight loss, diarrhea
  • Muscle weakness
  • Warm, wet skin
  • Temperature intolerance
  • Atrial fibrillation
  • Agitation
  • Hypercalcemia
  • Thrombocytopenia,, neutropenia. (Kocher blood)
71
Q

Organ failure thyreotoxic crisis

A
  • Kidney, liver, adrenal
  • A-fib and HF
  • Nausea, vomit, hypovolemia
  • Mental dysfunction, delirium, coma
  • Fever, hyperpyrexia
72
Q

Treatment thyreotoxic crisis

A
  • Thiamazole, methimazole
  • Propylthiouracil
  • Hormone release blockade: iodine solutions, lithium carbonate - not first
  • Propanolol, steroids (peripheral T4-T3 blockade)

Anesthesiology (13 decks)

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