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N931 Advanced Principles > Anesthetic Considerations for Urologic Surgery > Flashcards

Anesthetic Considerations for Urologic Surgery Flashcards

1
Q

What is a nephron?

A

outer cortex

inner medulla

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2
Q

How much cardiac output does a kidney receive?

A

20-25%

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3
Q

What are the three processes of the kidney that help with hemostasis?

A

filtration
reabsorption
tubular excretion

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4
Q

What is a normal GFR?

A

125ml/min

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5
Q

What nervous system innervates the kidney?

A

symapthetic nervous system

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6
Q

What are the six renal hormones?

A 
aldosterone
antidiuretic hormone
angiotensin
atrial naturetic factor
vitamin D
prostaglandins
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7
Q

What are the three effects of anesthetic drugs on the kidenys?

A

depress normal renal function
renal blood flow may decrease 30-40%
impairment of autoregulation

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8
Q

General anesthesia and kidney function is associated with a decrease in (4)

A

renal blood flow
GFR
urinary flow
electrolyte secretion

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9
Q

What do all volatile anesthetics due in the kidneys?

A

cause a mild increase in renal vasculature resistance

occurs in response to decrease in cardiac output and SVR

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10
Q

What 3 interventions can attenuate reductions in renal blood flow and GFR?

A

preoperative hydration, decreased concentrations of volatile anesthetics and maintenance of blood pressure

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11
Q

Sevoflurane has not been associated with

A

nephrotoxicity

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12
Q

Sevoflurane has been associated with what high levels? why?

A

fluoride

degraded by absorbants-> compound A (vinyl ether)

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13
Q

How can you decrease compound A toxicity?

A

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

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14
Q

What two volatile agents are not associated with nephrotoxicity?

A

isoflurane

desflurane (strongly resists biodegradation)

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15
Q

What is fluoride ion toxicity?

A

Fluoride interferes with active transport of sodium and chloride in loop of henle

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16
Q

Signs and symptoms of fluoride ion toxicity (5)

A 
polyuria
hypernatermia
serum hyperosmolality
elevated BUN and creatinine
decreased creatinine clearance
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17
Q

What is nephrotoxicity related to?

A

dose, duration and peak fluoride concentrations

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18
Q

Fluroride ion toxicity are potent:

A

vasodilator and potent inhibitor of many enzyme systems (ADH)

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19
Q

Definition of Acute kidney injury

A

a renal functional or structural abnormality that occurs within 48 hours
increase creatinine 0.3mg/dl or 50% increase; UO<0.5ml/kg/hr x 6 hours

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20
Q

What increases the risk of acute kidney injury?

A

hypovolemia
electrolyte imbalance
contrast dye

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21
Q

Causes of prerenal AKI

A

hypoperfusion of the kidneys without parenchymal damage

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22
Q

Examples of prerenal AKI

A

hemorrhage, V/D, diuretics, sepsis, shock, CHF, norepinephrine, NSAIDs, ACEi

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23
Q

Causes of intrinsic AKI

A

result of damage to the renal tissue

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24
Q

Examples of intrinsic AKI

A

tubular injury due to hypoperfusion, myoglobin, chemotherapy, infections, lymphoma, toxemia of pregnancy vasculitis

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25
Q

Causes of Post renal AKI

A

due to urinary tract obstruction

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26
Q

Examples of post-renal AKI

A

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

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27
Q

Four Risk factors of AKI

A

aging (> 50years, preoperative renal dysfunction)
comorbidities (cardiac and hepatic failure)
surgical procedures (cardiac bypass, aortic cross clamp, arteriography, intra-aortic balloon pump)
emergency or high risk procedures (ruptured AAA, ischemic times, large volume of blood transfusion)

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28
Q

AKI Preoperative Treatment includes

A 
fluid deficits 
attenuation of surgical stress
patient monitoring considerations (arterial line, TEE, CVP, foley catheter)
fluid replacement
improve cardiac output
normalize systemic vascular resistance
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29
Q

What is the most difficult AKI to treat?

A

intra-renal

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30
Q

How are fluid deficits treated pre-operatively for AKI?

A

balanced salt solutions- minimize ADH and RAAS activation

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31
Q

Describe fluid replacement perioperative treatment for AKI

A

500-1000ml bolus for hourly urine output below acceptable levels
colloids may not be superior crystalloids
high risk pateints: 0.5-1ml/kg/hr

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32
Q

Are diuretics used to prevent oliguria?

A

no, not recommended

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33
Q

early treatment of which AKI has the best outcomes?

A

pre-renal

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34
Q

How is the prognosis for post-renal AKI?

A

good prognosis with early identification

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35
Q

What is the most common cause of AKI?

A

prolonged hypo-perfusion

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36
Q

How is the severity of AKI determined?

A

duration and magnitude of initial insult

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37
Q

What is the treatment of AKI?

A

administering volume (normal saline) to euvolemia
improving cardiac output by afterload reduction
normalizing SVR

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38
Q

What is the “key strategy” of AKI peri-operative treatment?

A

limiting magnitude and duration of renal ischemia

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39
Q

How much does renal function decrease per decade?

A

10%

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40
Q

When does chronic kidney disease exist?

A

GFR is less then 60ml/min/1.73m2 for three months

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41
Q

When do S&S appear for CKD?

A

until less then 40% of normal functioning nephrons remain

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42
Q

What symptoms are present with 95% loss of renal function?

A

uremia, volume overload adn CHF

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43
Q

Stage 1 CKD

A

kidney damage with normal GFR

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44
Q

Stage 2 CKD

A

GFR 60-89ml/min/1.73m2 with kidney disease

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45
Q

Stage 3 CKD

A

GFR 30-59ml/min/1.73m2

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46
Q

Stage 4 CKD

A

GFR 15-29ml/min/1.72m2

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47
Q

Stage 5 CKD

A

GFR <15ml/min/ 1.73m2 with end stage failure

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48
Q

What are the cardiovascular symptoms seen in CKD?

A

hypertension and CHF (90% volume dependent; 10% secondary to increase renin), pericardial effusion
pericarditis
ischemic heart disease

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49
Q

When is pericarditis seen?

A

in patients with severe uremia

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50
Q

What is the most common cause of death in CKD?

A

ischemic heart disease (better outcomes with CABG then angioplasty)

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51
Q

What are the respiratory and neurologic effects of CKD?

A

respiratory depression secondary to delayed clearance
fatigue and weakness are early complaints
autonomic neuropathy

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52
Q

What are the hematologic effects of CKD?

A

normochromic, normocytic anemia and prolonged bleeding

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53
Q

How does CKD effect hematologic function?

A

decrease in erythropoietin production
reduction in erythrocyte life secondary to dialysis
blood loss from frequent sampling
decrease in platelet function
dialysis within 24 hours will correct bleeding

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54
Q

What increases levels of factor VIII?

A

desmopressin

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55
Q

Who is at higher risk for GI bleeding?

A

dialysis patients

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56
Q

What immune system changes occurs in CKD?

A

protein malnutrition

neutrophil, mococyte and macrophage changes

57
Q

What endocrine system changes occurs in CKD?

A

hyperparathyroidism

adrenal insufficiency

58
Q

What electrolyte changes occurs in CKD?

A

sodium wasting
hypocalcemia
hyperkalemia

59
Q

What are the treatments to hyperkalemia?

A

25-50 grams of dextrose
10-20 units of regular insulin
50-100mEq of sodium bicarb

60
Q

When should pre-operative levels of K be checked?

A

within 6-8 hours of surgery even if dialysis is performed

61
Q

What are the physiologic effects of dialysis?

A

hypotension, muscle cramping, anemia, nutritional depletion

62
Q

What are fluid management considerations with anesthesia in CKD?

A

UO 0.5-1ml/kg/hr recommended

mildly compromised function: balanced salt solution 3-5ml/kg/hr with 500ml bolus as needed

63
Q

What fluids are contraindicated in anuric patients?

A

potassium containing solutions (LR)

64
Q

Blood products are administered to CKD patients who

A

need increased oxygen carrying capacity

65
Q

How are fluids managed in renal insufficiency/ ESRD?

A

replacement volume deficit pre-operatively
intraoperative losses greater than 15% should replaced with colloid 1:1
crystalloid without potassium at 2-3ml/kg/hr

66
Q

How are fluids managed in the dialysis patient?

A

insensible loses- replace with 5-10ml/kg oof D5W

if urine is produced- replaced with 0.45% saline

67
Q

What is a normal serum creatinine?

A

0.7-1.5mg/dL

68
Q

For every 50% reduction in GFR, what will double?

A

serum creatinine

69
Q

What is a normal BUN ?

A

blood urea nitrogen

10-20mg/dL

70
Q

What is a normal BUN: Creatinine ratio?

A

10:1

71
Q

What is a normal creatinine clearance?

A

95-150ml/mi

72
Q

What is the most reliable test for renal function?

A

creatinine clearance

73
Q

What does creatinine clearance measure?

A

glumerular ability to excrete creatinine in urine
mild dysfunction 50-80ml/min
moderate dysfunction <25ml/min
<10mL/min requires dialysis

74
Q

How is pharmacologic sensitivity increased in CKD?

A

reduced protein binding

75
Q

What opioid and opioid metabolite is not removed by dialysis?

A

morphine

normerperidine

76
Q

What class of drug is highly dependent on renal excretion?

A

H2 blockers

77
Q

Regional anesthesia is a good option for CKD patients, but what are some concerns?

A

intolerance
coagulopathy
peripheral neuropathy
risk of infection

78
Q

Is block duration affected by renal failure?

A

no

79
Q

What are considerations for spinal and epidural placement in CKD?

A

platelet count
PT/PTT
ASRA coags

80
Q

What are pharmacokinetic properties of IV drugs during GA with CKD patients?

A

increased volume of distribution
decreased protein binding
low pH
renal excretion

81
Q

What drugs are less protein bound in CKD?

A

ketamine and benzodiazepines

82
Q

How is precedex cleared?

A

by the liver

83
Q

What opioid has reduced clearance in patients with ESRD?

A

remifentanil

84
Q

what is the precursor molecule to succinylcholine?

A

succinylmonocholine

85
Q

Cholinesterase deficiency occurs in what type of patients?

A

uremic patients

86
Q

Pancuronium is X% excreted where?

A

80% in the urine

87
Q

What NMD duration is not increased in renal failure?

A

atracurium, cisaturacurium and mivacurium

88
Q

Vecuronium and renal disease

A

approximately 30% excreted via renal system

effects rapidly revered with dialysis

89
Q

Rocurinium and renal disease

A

reduces clearance by almost 40%

90
Q

After major surgery, when should dialysis patients get dialysis?

A

24-36 hours after

91
Q

What may uremic patients require for replacement?

A

red blood cells
fresh frozen plasma
colloid solutions

92
Q

What is cystoscopy?

A

urologist uses a cystoscope to examine urethra and bladder

procedures can be quick or last hours

93
Q

What are anesthetic considerations for cystoscopy?

A

Local/MAC, Spinal anesthesia (offers relaxation with real-time patient assessment), general anesthesia (LMA vs ET)

94
Q

What position are patients in for a cystoscopy?

A

lithotomy

95
Q

ESWL

A

extra-corporeal shock wave lithotripsy

non-invasive treatment that uses high energy ultrasound waves to break up the calculi

96
Q

When is intervention required for nephrolithiasis?

A

renal calculi are >10mm

97
Q

What is common with ESWL?

A

hematuria

98
Q

What EKG placement is important in ESWL?

A

R wave used to trigger shocks

99
Q

What are ESWL contraindications?

A

active uti
uncorrected bleeding disorder or coagulopathy
distal obstruction
prengnacy

100
Q

What are complications to ESWL?

A

dose dependent hemorrhagic leisons on kidneys
perforation, rupture or damage to colon, hepatic structures, lung, spleen, pancreas, abdominal aorta or iliac veins
hematuria develops in most patients
diabetes, new onset HTN or decreased renal function

101
Q

What type of anesthesia can be used for ESWL?

A

GA (rapid onset, can control patient movement)
Spinal/epidural (t4/t6)
MAC
topical LA

102
Q

What are anesthetic considerations for ESWL?

A

d/c ASA, anticoagulants, platelet inhibitors and NSAIDs 7-10 days prior to procedures
document negative urine culture
HCG (ionizing radiation)
laser eye protection

103
Q

What is percutaneous nephrolithotomy?

A

procedure to remove kidney stones 25mm or smaller with rigid scope inserted in renal calyx under fluoroscopy

104
Q

Complications of percutaneous nephrolithotomy?

A 
anaphylaxis
bleeding
pain
fever
pneumothorax, hemothorax
renal colic
septicemia
UTI
105
Q

What class of medications is used to manage benign prostatic hyperplasia?

A

alpha blocking agents

106
Q

What is the most common surgical procedure for men over 60?

A

TURP

Transurethral resection of the prostate

107
Q

What is a TURP?

A

scope placed through urethra to cut away obstructing lobes of prostate
bladder distended and continuous irrigation used

108
Q

What are the anesthetic risk related to with TURPs?

A

patient age and associated comorbidities

109
Q

How is TURP commonly performed?

A

General anesthesia

110
Q

How is spinal anesthesia associated with TURP?

A

better anesthetic choice as it detects signs and symptoms of complications

111
Q

TURP syndrome

A

rare, but significant complication with mortality as high as 25%
large amount of fluid absorbed through the prostate

112
Q

What are the hallmark symptoms to TURP syndrome?

A 
related to combination of water intoxication, fluid overload, and hyponatremia
fluid overload
water intoxican
hyponatremia
glycine toxicity
113
Q

What are signs of fluid overload in TURP syndrome?

A

HTN bradycardia arrhythmia angina, pulmonary edema, CHF hypotension

114
Q

What are signs of water intoxication in TURP syndrome?

A

confusion, restlessness, seizure, lethargy, coma, dilated sluggish pupil

115
Q

What are signs of hyponatremia in TURP syndrome?

A

CNS changes, widened QRS, T wave inversion

116
Q

What are signs of glycine toxicity?

A

N/V, headache, transient blindness and myocardial depression

117
Q

What irrigation solutions cause TURP?

A

distilled water
saline
cytal (sorbitol and mannitol)
glycine

118
Q

What is the most common fluid used in TURP?

A

glycine

119
Q

What are complications of TURP syndrome?

A 
bleeding
bladder perforation
cardiac effects
dilutional hyponatremia with hypo-osmolality
hyperglycemia
hypothermia
glycine absorption
infection
renal toxicity (glycine)
skin burns
volume overload with pulmonary edema
120
Q

What devices have a greater incidence for skin burns during TURP syndrome?

A

monopolar cutting devices

121
Q

What is fluid absorption dependent on (TURP)

A 
size of resection
duration of resection
irrigation of solution pressure
number of venous sinuses open at one time
provider experience
122
Q

How much fluid can be absorbed per minute in TURP?

A

30ml

123
Q

How much fluid can be absorbed in 2 hours in TURP?

A

8L

124
Q

What happens to serum Na with fluid absorption from TURP?

A

uptake of 1L of irrigant can decrease serum Na 5-8mEq/L

serum Na <120meq/l associated with severe reactions

125
Q

What is glycine?

A

amino acid that acts as inhibitory transmitter

126
Q

What can excessive glycine absorption cause?

A 
nausea and vomiting
fixed and dilated pupils
headache
weakness
muscle incooridination
TURP blindness
seizures
hypotension
127
Q

How can you avoid TURP syndrome?

A

prevention!
avoid trendelenburg position
limit resection to less than one hour
place irrigating solution less then 60cm above prostate
monitoring electrolytes
use regional techniques with light sedation

128
Q

How do you treat TURP syndrome?

A 
early recongition
correcting hyponatremia
20mg IV furosemide
Labs (Hct, electrolytes, creatinine, glucose, ABG, 12 lead EKG)
IV midazolam 1mg  for seizures
intubate for pulmonary edema
PRBCs if needed
investigate for DIC or primary fibrosis
129
Q

How do you correct hyponatremia?

A

3-5% saline <100ml/hr
increase sodium 0.5mEq/hour or 8mEq/day
goal is sodium greater then 120mEq/l
rapid reversal can result in osmotic demyelination syndrome

130
Q

What are anesthetic concerns with laparoscopic urologic surgery?

A

pneumoperitoneum
urologic system is retroperitoneal- communicates with thorax- risk for SQemphysema
alterations in renal adn hepatic perfusion
CO2 absorption (potential acidosis)
extremes in patient position (increased intra-abdominal and intrathoracic pressures)
hemorrhage

131
Q

What are the two types of popular robotic urologic surgeries?

A

upper tract surgery (simple or radical nephrectomy, radical nephrouretectomy, nephron sparing surgery
Pelvic surgery: radical cystectomy, radical prostatectomy

132
Q

What are position considerations for robotic urologic surgery?

A

steep trendelenberg (+ lithotomy for prostatectomy) arms tucked at sides

133
Q

What are airway concerns for robotic urologic surgery?

A

airway assessment prior to extubation

134
Q

What is the duration and EBL for robotic urologic surgery?

A

3-4 hours

<300ml

135
Q

What are some considerations for robotic urologic surgery?

A

limit fluids until urethra is recommended (2 L total IVF)
large bore PIV +/- arterial line
DVT prophylaxis, eye protection, OGT, bair hugger, antibiotics, dexamethasone, remifentanil infusion common

136
Q

Anesthetic considerations for Nephrectomy

A 
Open vs laparoscopic
lateral jack-knife position
cardiovascular compromise
third spacing and edema
hemodynamic monitoring
postoperative pain management
137
Q

What is the mainstay treatment for ESRD?

A

renal transplant

138
Q

What is the most frequent solid organ transplant?

A

kidney

139
Q

Where is the transplanted kidney placed?

A

right or left extraperitoneal fossa (right side preferred)

attached via vascular anastomoses of external iliac artery and vein and ureter anastomosed to bladder

N931 Advanced Principles (14 decks)

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