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N931 Advanced Principles of Anesthesia I > Anesthesia for Urologic Surgery > Flashcards

Anesthesia for Urologic Surgery Flashcards

1
Q

how much cardiac output do the kidneys receive?

A

20-25%

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2
Q

nephron location

A

outer cortex

inner medulla

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3
Q

three processes of kidney that contribute to homeostasis

A
  • filtration
  • reabsorption
  • excretion (tubular)
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4
Q

normal GFR

A

125 mL/min

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5
Q

normal urine specific gravity

A

1.000-1.025

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6
Q

increased GFR

A
  • caused by increased renal blood flow
  • dilation of afferent
  • constriction of efferent
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7
Q

decreased GFR

A
  • caused by decreased renal blood flow
  • constriction of afferent
  • dilation of efferent
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8
Q

renal hormones include…

A
  • aldosterone
  • antidiuretic hormone
  • angiotensin
  • atrial naturetic factor
  • vitamin D
  • prostaglandins
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9
Q

anesthetic drugs effect on renal function

A
  • depress normal renal function
  • renal blood flow may decrease by 30-40%
  • impairment of autoregulation
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10
Q

general anesthesia associated with decrease in…

A
  • renal blood flow
  • GFR
  • urinary flow
  • electrolyte secretion
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11
Q

spinal and epidural

A
  • all the same as general anesthesia

- magnitude of change parallels the degree of sympathetic block and blood pressure depression

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12
Q

volatile anesthetic effects on kidneys

A
  • all cause mild increase in renal vascular resistance
  • compensatory mechanism in response to decreases in cardiac output and SVR
  • historically, methoxyflurane caused high fluoride ion concentrations and nephrotoxicity
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13
Q

prevention of effects of volatiles on kidneys

A
  • preop hydration
  • decreased concentrations of volatiles
  • maintenance of blood pressure
  • all attenuate reductions in renal blood flow and GFR
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14
Q

sevoflurane and the kidneys

A
  • not associated with nephrotoxocity even though it has been associated with high fluoride levels
  • degraded by absorbents to form compound A (vinyl ether)
  • potential exists for compound A nephrotoxocity
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15
Q

what can the CRNA do to decrease risk of compound A nephrotoxicity?

A
  • high gas flows (1 L/min FGF for 2 MAC hours)
  • decrease gas concentration
  • use of carbon dioxide absorbents
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16
Q

isoflurane and desflurane

A

-not associated with nephrotoxicity

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17
Q

fluoride ion toxicity

A
  • fluoride interferes with active transport of sodium and chloride in the loop of Henle
  • potent vasoconstrictor
  • potent inhibitor of many enzyme systems (ADH)
  • causes nephrotoxicity thorugh proximal tubular swelling and necrosis - related to dosage, duration, and peak fluoride concentrations
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18
Q

S/S fluoride ion nephrotoxicity

A
  • polyuria
  • hypernatremia
  • serum hyperosmolality
  • elevated BUN and Cr
  • decreased Cr clearance
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19
Q

acute kidney injury

A
  • renal functional or structural abnormality that occurs within 48 hours
  • increase in Cr 0.3 mg/dL or 50% increase
  • UOP < 0.5 mL/kg/hr x6 hours
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20
Q

AKI risk increased by what?

A
  • hypovolemia
  • electrolyte imbalance
  • contrast dye
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21
Q

prerenal AKI

A
  • hypoperfusion of kidneys without parenchymal damage

- ex = hemorrhage, N/V/D, diuretics, sepsis, shock, CHF, NE, NSAIDs, ACE-I

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22
Q

intrinsic AKI

A
  • result of damage to renal tissue

- ex = tubular injury d/t hypoperfusion, myoglobin, chemo, infection, lymphoma, toxemia of pregnancy, vasculitis

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23
Q

postrenal AKI

A
  • due to urinary tract obstruction

- ex = renal calculi, peritoneal mass, prostate/bladder urethra tumor, fibrosis, hematoma, strictures

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24
Q

risk factors for AKI

A
  • aging (>50 years of age)
  • preop renal dysfunction
  • comorbidities - cardiac failure, hepatic failure, DM, HTN
  • surgical procedures
  • emergency of high risk procedures
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25
Q

surgical procedures that put patient at increased risk for AKI

A
  • cardiac bypass
  • aortic cross clamp
  • arteriography
  • intra-aortic balloon pump
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26
Q

emergency or high risk procedures that put patient at risk for AKI

A
  • ruptured AAA
  • ischemic time
  • large volume of blood transfused
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27
Q

AKI preoperative treatment

A
  • fluid deficit replacement with balanced salt solution (to minimize ADH and RAAS)
  • attenuation of surgical stress (neuraxial, opioids)
  • patient monitoring considerations - art line, TEE, CVP, foley catheter
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28
Q

AKI Perioperative treatment

A
  • fluid replacement
  • improve CO
  • normalize SVR
  • diuretic use to prevent oliguria NOT recommended
  • early treatment of prerenal causes (10% mortality)
  • post renal – good prognosis with early identification
  • intrarenal AKI = most difficult to treat
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29
Q

prevention/management of AKI

A
  • most common cause = prolonged hypoperfusion
  • prophylaxis reduced mortality more than dialysis
  • duration and magnitude of insult determines severity of AKI
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30
Q

treatment of AKI

A
  • administer volume (NS) to euvolemia
  • improve cardiac output by afterload reduction
  • normalize systemic vascular resistance
  • key strategy = minimize magnitude and duration of renal ischemia
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31
Q

chronic kidney disease (CKD)

A
  • renal function decreases 10% per decade
  • CKD exists when GFR is less than 60 mL/min/1.73 m2 for three months
  • s/s not apparent until less than 40% of normal functioning nephrons remain
  • 95% loss of renal function = uremia, CHF, volume overload
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32
Q

CV effects of CKD

A
  • HTN and CHF
  • 90% volume dependent
  • 10% secondary to increased renin
  • pericardial effusion
  • ischemic heart disease most common cause of death
  • pericarditis seen in patients with severe anemia
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33
Q

respiratory effects of CKD

A

respiratory depression secondary to delayed clearance

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34
Q

neurologic effects of CKD

A
  • fatigue and weakness are early complaints

- autonomic neuropathy

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35
Q

disequilibrium syndrome

A
  • rapid increase in brain intracellular volume –> increased sodium
  • seizure, stupor, coma
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36
Q

hematologic effects of CKD

A
  • normochromic, normocytic anemia - decrease in EPO, reduction in RBC life d/t dialysis, blood loss from frequent sampling
  • prolonged bleeding - decrease plt function, DDAVP increases factor 8
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37
Q

GI effects of CKD

A

dialysis patients at greater risk for GI bleed, due to inflammation and mucosal changes

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38
Q

infection effects of CKD

A
  • protein malnutrition
  • neutrophil, monocyte and macrophage changes
  • leading cause of death in dialysis dependent patients
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39
Q

endocrine effects of CKD

A
  • hyperparathyroidism (hypocalcemia common so this is body’s way of compensating)
  • adrenal insufficiency (because on chronic steroids)
40
Q

electrolyte effects of CKD

A
  • sodium wasting
  • hypocalcemia
  • hyperkalemia
41
Q

hyperkalemia

A
  • serious disturbance in patients with renal disease
  • fatal dysrhythmias or cardiac standstill can occur when K+ levels reach 7-8 mEq/L
  • peaked t waves
  • wide QRS
  • wide PR
  • loss of P wave
  • sinusoidal wave
42
Q

treatment of hyperkalemia

A
  • 25-50g dextrose
  • 10-20 units regular insulin
  • 50-100 mEq sodium bicarb
  • hyperventilation
  • calcium (chloride or gluconate)
43
Q

physiologic effects of dialysis

A
  • hypotension
  • muscle cramping
  • anemia
  • nutritional depletion
44
Q

preop considerations for those with CKD

A
  • pertinent labs and diagnostics

- continue antihypertensives

45
Q

intraop considerations for those with CKD

A
  • monitoring
  • regional
  • general
  • fluid management
46
Q

postop considerations for those with CKD

A

dialysis with in 24 hours

47
Q

fluid management for those with CKD

A
  • UOP 0.5-1 mL/kg/hr recommended
  • mildly compromised function - balanced salt solution at 3-5 mL/kg/hr with 500 mL bolus PRN
  • potassium containing = contraindicated if anuric
  • blood products ONLY If need increased oxygen carrying capacity
  • renal insufficiency/ESRD - replace volume deficit preop; intraop loss greater than 15% replaced with colloid; NS, no fluid with K+
48
Q

fluid management for dialysis patient

A
  • insensible loss - replace with 5-10 mL/kg of D5W

- urine produced then replace with 0.45% saline

49
Q

serum creatinine

A
  1. 7-1.5 mg/dL

- for every 50% reduction in GFR serum Cr doubles

50
Q

BUN

A

blood urea nitrogen
10-20 mg/dL
BUN:Cr ratio 10:1

51
Q

Cr clearance

A

95-150 mL/min

  • most reliable test for renal function
  • measures glomerular ability to excrete Cr in urine
  • mild 50-80
  • moderate <25
  • dialysis <10
52
Q

pharmacologic considerations CKD

A
  • reduced protein binding –> increase sensitivity
  • morphine not removed by dialysis
  • meperedine metabolite (normeperedine) also NOT removed by dialysis
  • H2 blockers highly dependent on renal excretion
53
Q

major regional anesthetic concerns for those with CKD

A
  • intolerance
  • coagulopathy
  • peripheral neuropathy
  • risk of infection
54
Q

regional for those with CKD

A
  • regional WELL TOLERATED
  • block duration not affected by renal failure
  • spinal and epidural considerations - plt count, PT/PTT, ASRA Coags
55
Q

General Anesthesia and CKD

A
  • IV drugs –> volume of distribution increased, decreased protein binding, low pH, renal excretion
  • ketamine and benzos less protein bound
  • propofol appears safe
  • dex cleared by liver
  • remi - reduced clearace in patients with ESRD
56
Q

succinylcholine

A
  • increases serum potassium 0.5 mEq/L
  • succinylmonocholine (precursor to products of metabolism)
  • cholinesterase deficiency in uremic patients
57
Q

pancuronium

A

80% excreted in urine

58
Q

atracurium, cisatracurium, and mivacurium

A
  • duration not increased in renal failure

- slower onset with cisatracurium and mivacurium

59
Q

vecuronium

A
  • approximately 30% excreted via renal system

- effects rapidly revered with dialysis

60
Q

rocuronium

A

renal failure reduces clearance by almost 40%

61
Q

common urologic procedures (6)

A
  • cystoscopy
  • extra-corporeal shock wave lithotripsy (ESWL)
  • transurethral resection of the prostate (TURP)
  • laparoscopic/robotic urologic procedures
  • open nephrectomy
  • renal transplant
62
Q

cystoscopy

A
  • urologist uses cystoscope to examine urethra and bladder

- procedures can be quick or last hours

63
Q

cystoscopy anesthetic considerations

A
  • Local/MAC
  • spinal - offers relaxation with real time patient assessment
  • general - LMA vs ETT
64
Q

cystoscopy position

A

lithotomy

65
Q

extra-corporeal shock wave lithotripsy (ESWL)

A
  • non-invasive treatment that uses high energy ultrasound waves to break up renal calculi (kidney stones)
  • outpatient under general
  • water immersion no longer used
  • ECG placement important
  • hematuria common
66
Q

nephrolithiasis (renal calculi)

A
  • affect 9% of population
  • if calculi <5mm in diameter expected to pass without intervention
  • 5-10 mm = medical management
  • > 10 mm = unlikely to pass spontaneously
67
Q

ESWL contraindications

A
  • active UTI
  • uncorrected bleeding disorder or coagulopathy
  • distal obstruction
  • pregnancy
68
Q

ESWL complications

A
  • dose-dependent hemorrhagic lesions on kidneys
  • perforation, rupture or damage to colon, hepatic structures, lungs, spleen, pancreas, abdominal aorta, or iliac veins
  • hematuria develops in MOST patients
  • diabetes, new onset HTN or decreased renal function
69
Q

ESWL anesthesia

A
  • GA- rapid onset, can control patient movement
  • spinal/epidural at T4/T6 level
  • MAC
  • topical LA
70
Q

ESWL considerations

A
  • d/c ASA, anticoagulants, platelet inhibitors, NSAIDs 7-10 days before
  • document negative urine cx
  • HCG - because ionizing radiation
  • laser eye protection
71
Q

purcutaneous nephrolithotomy

A
  • procedure to remove kidney stones 25mm or smaller
  • GA and post op hospitalization
  • rigid scope inserted in renal calyx under fluoro
  • prone or supine position
72
Q

complications from purcutaneous nephrolithotomy

A
  • pain
  • fever
  • UTI
  • renal colic
  • septicemia
  • bleeding
  • pneumothorax, hemothorax
  • anaphylaxis
73
Q

transurethral resection of the prostate (TURP)

A
  • most common surgical procedure performed in men over 60
  • scope placed through urethra to cut away obstructing lobes of the prostate
  • bladder distended and continuous irrigation used
  • anesthetic risks r/t patient age and associated comorbidites
74
Q

medical management of BPH

A

alpha blocking agents

75
Q

TURP anesthetic considerations

A
  • commonly performed under general

- spinal anesthesia is anesthetic of choice because S/S complications better detected

76
Q

TURP syndrome

A
  • rare but significant complication
  • mortality 25%
  • large amounts of fluid absorbed through prostate
  • symptoms related to a combination of water intoxication, fluid overload, and hyponatremia
77
Q

fluid overload in TURP clinical manifestations

A
  • HTN
  • bradycardia
  • arrhythmia
  • angina
  • pulmonary edema
  • CHF
  • hypotension
78
Q

water intoxication in TURP clinical manifestations

A
  • confusion
  • restlessness
  • seizure
  • lethargy
  • coma
  • dilated sluggish pupils
79
Q

hyponatremia in TURP clinical manifestations

A
  • CNS changes
  • widened QRS
  • T wave inversion
  • irritability
  • 120 = EKG changes
  • 115 = widened QRS
  • 100 = v fib or vtach
80
Q

glycine toxicity in TURP clinical manifestations

A
  • N/V
  • HA
  • Transient blindness
  • myocardial depression
81
Q

TURP irrigation solutions

A
  • distilled water
  • saline
  • cytal (sorbitol and mannitol)
  • glycine
82
Q

complications of irrigation in TURP

A
  • volume overload with pulmonary edema
  • dilutional hyponatremia with hypoosmolality
  • cardiac effects
  • renal toxicity (glycine)
  • hyperglycemia
  • hypothermia
83
Q

additional complications of TURP

A
  • glycine absorption
  • bleeding
  • bladder perf
  • infection
  • skin burns - greater incidence with monopolar cutting devices; may impact patient with pacemaker
84
Q

fluid absorption in TURP syndrome depends on

A
  • size of resection
  • duration of resection
  • irrigation solution pressure
  • number of venous sinuses open at one time
  • provider experience
  • up to 30 mL of fluid absorbed per min (so up to 8 L in two hours)
85
Q

how much can 1 L of irrigant decrease sodium

A

5-8 mEq/L

86
Q

glycine absorption can lead to….

A
  • N/V
  • fixed and dilated pupils
  • HA
  • weakness
  • muscle incoordination
  • TURP blindness
  • seizures
  • hypotension
87
Q

TURP syndrome considerations

A
  • prevention is key when it comes to TURP syndrome
  • avoid trendelenburg
  • limit resection to less than 1 hour
  • place irrigating solution less than 60 cm above prostate
  • monitor electrolytes
  • use a regional technique with light sedation
88
Q

TURP syndrome treatment

A
  • early recognition
  • correcting hyponatremia (3-5% saline no greater than 100mL/hr; increase sodium SLOWLY, goal greater than 120, rapid reversal can cause osmotic demyelination syndrome)
  • 20 mg IV lasix
  • labs/tests - Hct, lytes, Cr, glucose, ABG, 12 lead
  • IV midaz 1 mg at a time for seizures
  • intubate for pulmonary edema
  • PRBCs if necessary
  • investigate for DIC or primary fibrinolysis
89
Q

Anesthetic concerns for laparoscopic urologic surgery

A
  • pneumoperitoneum
  • urologic system is retroperitoneal - communicates with thorax so risk for subQ emphysema
  • alterations in renal and hepatic perfusion
  • CO2 absorption - potential for acidosis
  • extremes in patient position
  • hemorrhage
90
Q

two categories of robotic urologic surgery

A
  • upper tract surgery - simple or radical nephrectomy, radical nephroureterectomy, nephron sparing surgery
  • pelvic surgery - radical cystectomy, radical prostatectomy
91
Q

robotic urologic surgery position

A 
steep trendelenburg (+ lithotomy for prostatectomy), arms tucked at sides
*airway assessment before extubation*
92
Q

robotic urologic surgery duration

A

3-4 hours

93
Q

robotic urologic surgery EBL

A

<300 mL

94
Q

robotic urologic surgery additional anesthetic considerations

A
  • limit fluids until urethra reconnected
  • large bore PIV +/- art line
  • additional = DVT prophylaxis, eye protection, OGT, bair hugger, antibiotics, dexamethasone, remi infusion common
95
Q

nephrectomy anesthetic considerations

A
  • open vs. laparoscopic
  • lateral jack knife position
  • CV compromise
  • third-spacing and edema
  • hemodynamic monitoring
  • postop pain management
96
Q

renal transplant

A
  • mainstay tx for ESRD
  • donors may be living or deceased
  • most frequent solid organ transplanted today
  • 5 year survival rate is 70%
  • living donor - ORs are usually next door
  • transplanted organ placed in R or L extraperitoneal fossa (R side preferred)
  • transplanted kidney attached via vascular anastomoses of external iliac artery and vein and ureter anastomosed to bladder
  • GA - prop, cis, art line, CVP monitoring
  • immunosuppressant therapy

N931 Advanced Principles of Anesthesia I (19 decks)

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