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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
Normal GFR
125 ml/min
26
Factors influencing GFR
- Blood flow - Hydrostatic pressures - Blood protein conc - Membrane permeability - Glomerulo-capillary surface are (can be reduced after nephrectomy or by glomerular diseases)
27
Types of tubular transports
- Endocytosis (proteins) - Passive diffusion - Active transport - Facilitated diffusion
28
Consequences off impaired kidney function
- Proteinuria (albumin) - Loss of conc/dilution - Uremia - Acidosis (acid retention) - Sodium retention (loss of Na excretion, hyperaldosteronism) - Water retention
29
Clinical signs of AKI
- Azotemia (incr BUN, creatinine and uric acid) | - Uremia (=azotemia + clinical signs)
30
Uremia AKI
Azotemia + clinical signs: - Nausea - Confusion - Acidosis, Kussmaul breathing - Edema - Infections - Electrolyte disturbances
31
Risk factors of AKI
- Chronic kidney insuff (acute-on-chronic) - Hypoxemia - Volume depletion - Urine infections - Diabetes, old, congestive HF, post-op
32
AKI prerenal causes
60-80 % - Decreased CO - Volume-redistribution - Fluid depletion
33
AKI renal causes
15-25 % - Nephrotoxic agents - Ischemia - Glomerular diseases - Interstitial nephritis - Infection-associated nephropathies
34
AKI postrenal causes
9-12 % - Infections - Oncology - Vascular (e.g aneurysm) - Papillar necrosis (DM, analgetics) - Tubular (urate, methotrexate) - Miscellaneous (stones, ligature, blocked bladder catheter)
35
RIFLE
AKI classification - Risk - Injury - Failure - Loss (Persistant ARF over 4 weeks) - ESRD (end-stage renal disease) * Consider GFR, creatinine and urine output
36
AKI - Risk (RIFLE)
- Creatinine x 1,5 - GFR decr over 25 % - Urine output less than 0,5 ml/kg for 6 hr
37
AKI - Injury (RIFLE)
- Creatinine x 2 - GFR decr over 50 % - Urine output less than 0,5 ml/kg for 12 hrs
38
AKI - Failure (RIFLE)
- Creatinine x 3 - GFR decr over 75 % - Urine output less than 0,3 ml/kg for 12 hr
39
AKIN criteria (2012)
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
Early biomarkers of AKI
- NGAL (!) - Cystatin-C, KIM-1, IL18 - TIMP-2 - IGFBP-7)
41
Conservative antiuremic treatment
- Fluid restriction + diuretics - Electrolyte control - Protein intake (0,2-0,3 g/kg) - Acid-base homeostasis - Enhance renal perfusion (MAP, dopamine?)
42
Carboanhydrase blocker diuretics
Azetalzolamide - Prox. Tubule - Clinical use: metabolic alkalosis, glaucoma, decrease fluid secretion
43
Loop diuretics
Furosemide, etacrinic acid
44
Loop duretics SEs
- Hypochloremia - Hypokalemia - Hypomagnesemia - RBF increase - Ototoxic - Block pancreas (hyperglycemia) - Dyslipidemia Cave: anuria
45
Thiazide diuretics
Hydrochlorthiazide, chlortalidone, clopamide - Distal tubule - Clinical use: GFR over 30 ml/min
46
Potassium-sparing diuretics
Spironolactone, ailoride, triamterene - Aldosterone antagonists - Na block
47
Triamterene SE
Megaloblastic anemia
48
Osmotic diuretics
Glycerine, mannitol - SE: cardiac decompensation, high serum osmolarity (mannitol) - Don´t give in ARF (tubular necrosis)
49
Renal replacement therapies (RRTs)
- Hemofiltration - Hemodialysis - Hemodiafiltration - Plasmapheresis - Hemoperfusion - MARSH
50
Indications of RRT
- 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
Hemofiltration
- Based on hydrostatic pressure difference | - Filtration influenced by filtration pressure and oncotic pressure
52
Stopping RRT
- Cease of indication criteria - Urine output over 1 ml/kg/hr for 24 hrs - Fluid balance can be kept without RRT - RRT complication
53
Hemoperfusion
- Absorption of blood solved toxins - Active carbon, resine - FLuid substitution not necessary - Can remove: many medicines and poisons
54
Plasmapheresis
- Separation of plasma from blood - Fresh plasma replacement to circulation - Can remove huge molecules and bound complexes!
55
Types of phereses
- Centrifugal separator | - Continous membrane separator
56
Indications plasmapheresis examples
- Guillain-Barré SY, Myasthenia gravis - Hyperviscosity, TTP/HUS/HELLP - Goodpasture syndrome
57
Hepatic failure criteria (labs)
- SeBi over 34 mmol/l (48 hrs) - SGOT (AST) 2x normal value - Se Albumine decrease - Se cholesterine decrease
58
Hepatic failure - organ dysfunction
- Hepato-renal syndrome - Hepatic coma - Hepato-pulmonal SY - Secondary hyperaldosteronism
59
Most common causes of hepatic failure
- Acetaminophen - Hepatitis B - Drug - Hepatitis A
60
Clinical signs hepatic failure
- Confusion, coma - Jaundice - Tachycardia, low BP - Small, shrunken liver - Ascites - Peripheral edema, warm extremities
61
Prognosis of hepatic failure
Child-Pugh, consideres: - Encephalopathy - Ascites - INR - Albumine - Bilirubin * Each parameter gets 1-3 point, higher points increases mortality
62
MELD
Model for End-stage Liver Diasease score (for transplantation - COnsideres bilirubin, INR and creatinine
63
Evaluation of hepatic failure (labs)
- GOT, GTP (liver cell cytosol-destruction, low in cirrhosis) - ALP (cholestasis) - Coagulation tests (not vWF!!, tests PT and factor VII) - Albumin
64
Clinical signs of hepatic encephalopathy
- Seizures - Arching neck - Dilated pupils, sluggish or no response - Pronation of hands - Hyperextended extremities
65
Cardiovascular effects of hepatic failure
- Cardiomyopathy - Hyperdynamic circulation - Microcirculatory disturbances - Portal HT - Anemia, thrombopenia (hypersplenia)
66
Hepato-pulmonal syndrome
- Restrictive lung disease - Decreased contact-time in lung - Absence of hypoxic vasoconstriction in lung - Pulmonal HT - Porto-pulmonal HT (over 25 mmHg)
67
Hepato-renal syndrome
- Concomittant kidney injury - Enhanced RAAS activity - Secondaru ADH activation - TXA and endothelin activation
68
Thyreotoxic crisis
Acute , life-treathening form of thyreotoxicosis
69
Precipitating factors of thyreotoxic crisis
- Infection - Trauma or manipulation by surgery - Non-thyroid operations - Pregnancy, pre-eclampsia - Drugs: amiodarone, iodine contrast, thyroxine overdose
70
Signs and symptoms thyreotoxic crisis
- Weight loss, diarrhea - Muscle weakness - Warm, wet skin - Temperature intolerance - Atrial fibrillation - Agitation - Hypercalcemia - Thrombocytopenia,, neutropenia. (Kocher blood)
71
Organ failure thyreotoxic crisis
- Kidney, liver, adrenal - A-fib and HF - Nausea, vomit, hypovolemia - Mental dysfunction, delirium, coma - Fever, hyperpyrexia
72
Treatment thyreotoxic crisis
- 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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