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Renal > Diuretics and Anesthesia > Flashcards

Diuretics and Anesthesia Flashcards

1
Q

What are the two major pathways of natriuretic peptide (NPs) actions?

A
  1. Vasodilator effects

2. Renals effects that leads to natriuresis and diuresis.

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2
Q

What are NP’s direct effects on veins?

A

Dilate veins (increase venous compliance and decrease CVP)

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3
Q

What are NP’s effect on cardiac output and how?

A

Reduce CO by decreasing ventricular preload

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4
Q

What are NP’s affects on arteries?

A

Dilate arteries which decreases SVR and systemic arterial pressure

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5
Q

How does NP affect the kidney?

A

Increasing glomerular filtration rate which produces natriuresis and diuresis

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6
Q

What is natriuresis?

A

Increased sodium excretion

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7
Q

What is the second renal action of NPs?

A

They decrease renin and therefore decrease angiotensin II and aldosterone

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8
Q

T/F: NPs serve as a counter-regulatory system for the RAAS?

A

True

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9
Q

What produces Atrial natriuretic peptide?

A

Atrial myocytes

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10
Q

What is the stimuli for releasing ANP?

A

Atrial stretch

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11
Q

Where is brain natriuretic peptide synthesized?

A

Ventricles of the brain

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12
Q

What causes BNP to be released?

A

Atrial stretch, sympathetic stimulation, angiotensin II

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13
Q

What are the 3 affects of ANP/BNP on the kidneys?

A
  1. Decrease Renin
  2. Decrease angiotensin II and aldosterone
  3. Increase GFR
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14
Q

What are NP’s affects on pulmonary capillary wedge pressure?

A

Reduced

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15
Q

Diuretic definition:

A

A substance that increases the rate of urine volume output

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16
Q

How do most clinicallty used diuretics act?

A

By decreasing the rate of Na+ reabsorption from the tubules which causes Na+ output to increase which then results in diuresis

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17
Q

What are common clinical use for diuretics?

A

To decrease ECF volume, to treat edema, CHF, or hypertension

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18
Q

What eventually overrides the effects of diuretics?

A

Decrease ECF leads to decreased MAP leads to decreased GFR leads to increased Renin and angiotensin II

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19
Q

Site of action for K+ sparing diuretics?

A

Collecting duct

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20
Q

Site of action for Loop diuretics?

A

Loop of Henle (ascending thick mostly)

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21
Q

Site of action for thiazides?

A

Distal convoluted tubules

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22
Q

Site of action for carbonic anhydrase inhibitors?

A

Proximal convoluted tubules

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23
Q

Example of osmotic diuretic?

A

Mannitol (or urea)

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24
Q

What is mechanism of action of mannitol?

A

These substances injected into the bloodstream are filtered and not easily reabsorbed and ultimately they draw fluid into the tubules (increasing urine output)

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25
Q

Is glucose a diuretic?

A

Yes and no. For diabetics, glucose can act as a diuretic when spilling over into the urine resulting in increased urine output

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26
Q

3 examples of loop diuretics?

A

furosemide, bumetanide, ethacrynic acid

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27
Q

What is mechanism of action for loop diuretics?

A

Inhibit the Na-2Cl-K cotransporter in the TAL of the Henle’s Loop.

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28
Q

What is the most commonly used diuretic?

A

Thiazide diuretics

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29
Q

Example of thiazide diuretic

A

hydrochlorothiazide (HCTZ)

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30
Q

What is mechanism of action for thiazide diuretics?

A

These agents inhibit sodium chloride reabsorption in the early distal tubule

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31
Q

Example of Carbonic Anhydrase Inhibitor:

A

Acetazolamide (diamox)

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32
Q

What is mechanism of cation for carbonic anhydrase inhibitors?

A

Reduce reabsorption of Na+ in the proximal convoluted tubule by decreasing HCO3

33
Q

What is the disadvantage of using carbonic anhydrase inhibitors?

A

It causes acidosis through HCO3 loss in the urine

34
Q

What is main reason for use of carbonic anhydrase inhibitors?

A

Glaucoma

35
Q

What is another name for Potassium-sparing diuretics?

A

Aldosterone Antagonists

36
Q

What is an example of a potassium sparing diuretic?

A

Aldactone

37
Q

What is mechanism of action for potassium sparing diuretics?

A

Decrease reabsorption of Na+ and decreases K+ secretion by competing for aldosterone binding sites in the distal segment of the distal tubule;

38
Q

Aldactone is often used in conjunction with what other diuretics to prevent hypokalemia?

A
  1. Thiazides

2. Loop diuretics

39
Q

Example of Na+ channel blockers:

A

Amiloride and triamterene

40
Q

What are the two main categories of Renal Failure?

A
  1. Acute Kidney Injury (AKI)

2. Chronic Kidney Injury (CKD).

41
Q

T/F: CKD and AKI are both completely reversible with proper therapy?

A

False; CKD is irreversible

42
Q

What are the three main categories of Acute Renal Failure?

A
  1. Pre-renal
  2. Intra-renal
  3. Post-renal
43
Q

Which ARF is typically caused by toxins, infections, autoimmune diseases. and direct renal injury?

A

Intra-renal

44
Q

What are common causes of pre-renal ARF?

A

Heart failure, hypovolemia (kidney not getting enough blood flow and becomes ischemic).

45
Q

What are common causes of post-renal ARF?

A

Stones, urethtral valves, tied off ureter, kinked foley.

46
Q

At what percent of functioning nephrons are symptomes of Chronic Kidney disease present?

A

Once functioning nephrons decreases to at least 70% below normal

47
Q

What is the definition of CKD?

A

Kidney damage or decreased kidney function that persists for at least 3 months

48
Q

At what point can relatively normal blood concentration of electrolytes and body fluid volumes be maintained until?

A

Once functioning nephrons decreases below 20-25% of normal

49
Q

What are mechanisms of injury leading to Chronic Renal Failure?

A
  1. Injury to renal vasculature
  2. Glomerulonephritis
  3. Infection
  4. Nephrotic syndrome
50
Q

What is vesicoureteral reflux?

A

When the bladder wall fails to occlude the ureter during micturation and contaminated urine from the lower urinary tract is propelled retrograde into the kidney

51
Q

What is nephrotic syndrome?

A

Condition where large amounts of protein are lost in the urine due to destruction of or loss of negative charge on the capillary basement membrane in the glomerulus

52
Q

Why does anemia occur in ESRD?

A

Anemia occurs because of decreased synthesis by the kidney of erythropoietin (which acts to stimulate RBC production in bone marrow).

53
Q

What is the number one cause of DB and HTN and therefore most important risk factor for ESRD?

A

Obesity

54
Q

What are some other effects of renal failure?

A
  1. Abnormal glucose tolerance
  2. Platelet and WBC dysfunctiom
  3. Hypersecretion of gastric acid increases risk of ulcers
  4. Autonomic neuropathy can slow gastric emptying
  5. Peripheral neuropathy is common
55
Q

How does renal failure cause HTN?

A

Decrease water and sodium excretion promotes HTN

56
Q

T/F: HTN can only occur if both kidneys have ischemia?

A

False; one kidney will increase renin and angiotensin II to increase BP

57
Q

What are the two main ways of hypertension control from renal disease?

A
  1. Increasing GFR

2. Decreasing tubular reabsorption

58
Q

What does the rate of movement of solute across the membrane depend on (dialysis)?

A
  1. Concentration gradient
  2. Permeability and surface area
  3. Length of time
59
Q

Indications for dialysis?

A
  1. Fluid overload
  2. Hyperkalemia
  3. Severe acidosis
  4. Metabolic encephalopathy
  5. Pericarditis
  6. Coagulopathy
  7. Refractory GI symptoms
  8. Drug toxicity
60
Q

How much does GFR decrease with age?

A

Decrease by 5% per decade after age 20

61
Q

Barbiturates and renal function?

A

Pt more susceptible to these agents probably because of decreased protein binding (more free drug available)

62
Q

What does poor renal function have on propofol/ketamine/etomidate?

A

No significant difference

63
Q

Benzodiazepines with renal failure?

A

May have additional sensitivity

64
Q

Dexmedatomidine and renal failure?

A

Longer-lasting sedative

65
Q

Opioids with renal failure?

A

Morphine/demerol/ hydromorphone have an accumulation of metabolites

66
Q

NMBA to avoid with renal failure?

A

Pancuronium, pipecuronium, alcuronium, doxacurium, (mild concern with vec/roc and succ with K+>5.0)

67
Q

Where is dexmedetomidine primarily metabolized?

A

Liver

68
Q

What NMBA is drug of choice with renal failure and why?

A

Cisatracurium as it is degraded by Hoffman elimination

69
Q

Which two volatile agents should we be cautious with in renal failure?

A
  1. Enflurane

2. Sevoflurane

70
Q

Elective surgery: what is the K+ threshold to put off surgery until dialyzed?

A

> 5.5 mEq/L

71
Q

At Hamot, what is the typical waiting time after dialysis to do elective surgery?

A

6-8hrs after

72
Q

Why is controlled ventilation advantageous for renal failure patients?

A

Will decrease the risk of respiratory acidosis which is not good in the setting of metabolic acidosis

73
Q

What is mortality rate of post-op renal failure?

A

50%

74
Q

What are precautions/treatments to prevent post-op renal failure?

A
  1. Euvolemia
  2. Prophylactic mannitol
  3. Dopamine renal dosing
75
Q

What is most common stone composition of kidney stones?

A

Calcium oxalate

76
Q

What are pharmacologic treatment for kidney stones?

A
  1. Toradol
  2. Opioids
  3. Alpha blocker (decrease ureter tone)
77
Q

Where does tissue damage occur during ESWL?

A

At the air tissue interface so lung and intestine must be out of the way

78
Q

When should ESWL shock wave be delivered?

A

20 ms after the r wave

79
Q

What are most common causes of gout?

A

Diet rich in protein, fat, and alcohol

Renal (5 decks)

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