E3 - Genitourinary Procedures Flashcards
What position will the patient most likely be in for Urological Surgery?
A. left lateral decubitus
B. lithotomy
C. prone
D. supine
B. Lithotomy
so consider all the possible nerve/finger/vessel injuries
common peroneal, femoral and obturator nerve injuries; fingers crushed by bed; lift legs up at same time to prevent torsion
What lab is the best measure of glomerular function?
- GFR
What is normal GFR?
When will patients become symptomatic?
- 125 mL/min
- asymptomatic until a 50% drop (so at 75 mL/min)
What will be the result of moderate GFR insufficiency? select 3.
A. increased BUN/creat
B. decreased BUN/creat
C. increased energy
D. decreased energy
E. acidemia
F. anemia
A. ↑ BUN/Creat
D. Decreased energy
F. Anemia
What will be the result of severe GFR insufficiency?
A. profound uremia
B. alkalosis
C. volume overload
D. A & C
E. all of the above
D. A & C
- Profound uremia (high levels of waste product in the blood)
- volume overload
- acidemia
What is a Normal BUN?
- 8-18 mg/ dL
influenced by exercise, steroids, dehydration
BUN will not be elevated in the kidney disease until GFR is ____% of normal.
A. 45
B. 50
C. 60
D. 75
D. 75%
What is normal Creatinine?
- 0.8 - 1.2 mg/dL
Higher in men d/t more muscle mass
Expected findings on a preop evaluation of a pt with Chronic Renal Failure include: select 3.
A. a fib
B. acidosis
C. volume deficiency
D. HTN
E. iron deficient anemia
F. hypokalemia
B. Acidosis (↓ production of ammonia, ↑ Anion Gap)
D. HTN d/t RAAS dysfunction
E. Hematologic Symptoms like iron deficient anemia & abnormal plt aggregation
* Hyperkalemia
* Hypervolemia (↑Na = ↑H2O)
Because most anesthetic drugs are lipid soluble in a non-ionized state, termination doesn’t depend on ____.
A. metabolism
B. redistribution
C. renal excretion
D. hepatic clearance
C. Renal Excretion
Metabolite of these drugs are excreted as water-soluble compounds
Drugs of concern for patients with Renal Insufficiency are:
Select 2
A. highly ionized and eliminated lipid-soluble in urine
B. nonionized and eliminated lipid-soluble in urine
C. highly ionized and eliminated unchanged in urine
D. nonionized and eliminated unchanged in urine
C. Drugs that are highly ionized and eliminated unchanged in urine
List:
* Muscle relaxants (Pancuronium)
* H2-R Blockers (ranitidine, cimetidine)
* Cholinesterase inhibitors (neostigmine)
* Thiazide diuretics
* Digoxin
* Many antibiotics (PCNs, tetracycline)
* Active metabolites (morphine/codeine/meperidine/ketamine/midazolam)
An endoscopic evaluation of the lower urinary tract that goes thru the urethra is called:
A. colonoscopy
B. hysteroscopy
C. urethroscopy
D. cystoscopy
what about scope thru the bladder? thru the ureteral orifice?
C. Through urethra = urethroscopy
Through bladder = cystoscopy
Through ureteral orifice = ureteroscopy
Describe the process of a scope urologic procedure:
A. guide wire inserted thru scope
B. catheter/instruments placed over wire
C. radiopaque dye injected thru catheter
D. all of the above
D. all of the above
can be rigid or flexible scope
A urethroscopy/cystoscopy visualizes the urethra and/or bladder due to urinary symptoms like pain, burning, hematuria, and difficulty urinating. What diagnosis can be made from these procedures?
A. kidney stones
B. duodenal ulcers
C. lesions and strictures
D. bowel perforations
C. lesions and/or strictures
can dilate stricture, treat cystitis, stent placement, and/or resect tumors
What is the procedure of choice for mid/distal ureter or bilateral stones?
A. cystoscopy
B. ureteroscopy
C. urethroscopy
D. colposcopy
B. Ureteroscopy (flexible scope)
Can incorporate laser technology
What percentage of men and women lifetime will experience ureter stones?
What is the recurrence percentage?
- Men: 10%
- Women: 5%
- Recurrence: 50%
Fill in the blanks:
Ureter stones are diagnosed on ____, ____, and/or _____. Select 3.
A. MRI
B. CXR
C. CT
D. KUB xray
E. IV pyelogram
C. CT
D. KUB (kidneys, ureter, bladder) xray
E. IVP (Intravenous Pyelogram)
What are some examples of medical expulsive therapy (MET) for ureter stones? Select 3.
A. loop diuretics
B. aggressive fluid admin
C. antibiotics
D. CCB or alpha-blockes
E. NSAIDs
F. bicarb drip
B. Aggressive Fluid intake (↑ Water, ↑ Cranberry Juice)
D. CCB and alpha blockers to vasodilate
E. NSAIDs
or they can proceed to surgery/procedures (stone basket, SWL, perc nephrolithotomy)
Shock wave Lithotripsy (SWL) is best suited for what size intranephric stones?
small/medium
Shock Wave Lithotripsy (SWL) runs a risk of:
A. hypothermia
B. TUR syndrome
C. sub-capsular hematoma
D. severed ureter
C. Risk of kidney injury or sub-capsular hematoma
Compare the Old SWL vs New SWL.
- Old SWL: Water baths, hypothermia, painful
- New SWL: Water-filled coupler device, focus beam, decrease pressure pulse, less painful
What are the 2 ABSOLUTE contraindications to SWL?
A. large calcified aortic/renal aneurysms
B. bleeding disorder/AC
C. untreated UTI
D. pacemaker/ICD
E. pregnancy
B. Bleeding disorder/ anticoagulants
E. Pregnancy (we do not thump babies)
Relative CIs: Large calcified aortic/renal aneurysm, untreated UTI, Obstruction distal to renal calculi, Pacemaker, ICD, neurostimulator, Morbid Obesity.
What are preoperative anesthetic considerations for SWL and percutaneous nephrolithotomy? select 2
A. cannot use a laser with either procedure
B. single PIV
C. no versed
D. appropriate abx w/in 1 hr of cut time
B. Single PIV
D. Appropriate ABX within 1 hour “cut time”
and:
* Consider anxiolytics
* Iodine Allergy?
What are intraoperative anesthetic considerations for Shock Wave Lithotripsy? select 2.
A. only done under general with an ETT
B. minimal narcotic
C. lateral position
D. use eye coverings if laser used
B. Minimal narcotics
D. Eye covering for laser (document!)
and:
* Local vs. General (most people will be general)
* LMA vs ETT
* Consider antiemetic
* Lead for providers (cover breast, thyroid, sex organs, corneas)
What procedure will be indicated for large intranephric stone removal?
A. percutaneous nephrolithotomy
B. SWL
C. stone basket
D. laser therapy
A. Percutaneous Nephrolithotomy
A percutaneous nephrolithotomy is useful for large intranephric stones but not as commonly done as SWL. What does this procedure require in order to prevent obstruction as fragments pass?
A. water bath
B. stone basket
C. water-filled coupled device
D. initial placement of ureteral stents
D. initial placement of ureteral stents
Minimally-invasive procedure to remove stones from the kidney by a small puncture wound through the skin.
What are 2 drawbacks to percutaneous nephrolithotomy?
A. hypothermia risk
B. uses more fluoroscopy
C. transurethral resection syndrome is possible
D. risk of subcapsular hematoma
B. Uses more fluoroscopy
C. Transurethral Resection syndrome possible
What are some intraoperative anesthetic considerations for percutaneous nephrolithotomy? Select 2
A. local anesthesia usually
B. GETA
C. might need a pudendal nerve block
D. should use short-acting NMBDs
E. no narcotics
B. General ETT
D. Short NMBD’s (vec/roc)
Also:
* Lateral position (bean bag, pillows)
* Lead apron for provider
* Eye covering for laser (document!)
what position do we want the pt for perc nephrolithotomy? and what kind of protection should be used for the provider?
A. supine; lead apron
B. lateral; eye protection and lead apron
C. prone; eye protection
D. lithotomy; eye protection and lead apron
B. lateral position; should use eye protection if using laser and wear a lead apron
Name the 3 scrotal operations discussed.
- orchiectomy (remove testicles)
- hydrocelectomy (remove fluid-filled sac around testicle)
- testicular torsion (spermatic cord twists, cutting off blood supply to testicle, medical emergency!)
Testicular torsion is a MEDICAL EMERGENCY and must be performed within ____ hours to prevent irreversible ischemic damage.
A. 24 hrs
B. 12 hrs
C. 6 hrs
D. 4 hrs
C. 6 hours
he’s gonna lose his testicle if u dont hurry
What are 2 main indications for circumcision in adult males?
A. phimosis
B. penile/prostate cancer risk
C. cosmetic
D. squamous cell carcinoma
A. Phimosis (tight foreskin)
B. Penile/ prostate cancer risk
What is a Penectomy? And what may the procedure include?
A. surgical removal of one or both testicles; may include prosthesis
B. surgical removal of the penis; may include prosthesis
C. surgical removal of one or both testicles; may include inguinal lymph node biopsy
D. surgical removal of the penis; may include inguinal lymph node biopsy
D. Removal of the penis; usually to remove squamous cell carcinoma on the penis. This procedure may include inguinal lymph node biopsy.
What 2 patient populations may require a penile prosthesis?
- Diabetic patients
- Spinal cord injury patients
What are 2 specific anesthesia considerations for penile operations? select 2.
A. careful with prosthesis touching skin prior to insertion
B. need to change to lateral positioning mid-case
C. need a pudendal nerve block
D. tachycardia is likely
A. SCIP + take care with prosthesis touching skin before insertion
C. Penile Block: pudendal nerve (S2-S4)
other general considerations:
* Preop anxiolytics
* General: ETT vs LMA
* Supine
* Manipulation of genitals = will vagal down/bradycardia, have glycopyrrolate ready
A cystectomy is surgical removal of all or part of the urinary bladder. What is the difference between a simple vs radical cystectomy?
A. simple cystectomy removes the ureters, prostate/uterus, ovaries
B. simple cystectomy is mainly for benign conditions like radiation cystitis
C. radical cystectomy removes only the inflammed areas
D. radical cystectomy can treat hemorrhagic cystitis
B. simple cystectomy treats benign conditions: like radiation cystitis or hemorrhagic cystitis
radical is for malignant conditions like invasive bladder cancer and removes ureters, prostate/uterus, ovaries.
What are 2 preop anesthetic considerations for cystectomy?
A. require a penile block
B. GETA is the only option
C. get an EKG if they’re on anticoagulation
D. bowel prep likely
C. Anticoagulant use? EKG
D. Bowel prep likely so probably more on the dehydrated side?
What is a possible anesthetic option besides using only GETA for cystectomy?
A. local
B. SAB
C. regional
D. bier block
B. SAB, epidural, GETA
position: supine, and don’t forget SCIP
Common complications with a cystectomy includes: select 3
A. hypothermia
B. hypervolemia
C. hypertension
D. excessive blood loss
E. 3rd space losses
F. hyponatremia
A. Hypothermia (Bair Hugger or underbody water blankets)
D. Blood loss: up to 3L (get 2 PIVs, type and crossmatch blood)
E. 3rd space losses d/t open belly
What procedure is the gold-standard for BPH?
A. penectomy
B. TURP
C. hypospadius repair
D. penile prosthesis
B. Transurethral Resection of Prostate (TURP)
- involves cutting away a section of the prostate using a laser or electrocautery.
and this is done AFTER failure of med therapy and recurrent sx; likely ELDERLY!!
What is the estimated blood loss of a TURP procedure?
100-200 cc’s
if not an open resection
uses electrocautery or laser
T/F: Men over 80 yrs old are 90% affected by BPH, which will likely be the most common patient population for TURP procedure.
True.
that gland just never stops growing…
What are preoperative anesthetic considerations for TURP procedures? select 2.
A. 3rd space losses
B. get a large bore IV (18 or 16G)
C. bowel prep likely
D. consider epidural
E. is the patient on anticoagulants?
B. Large bore IV (18G or 16G)
E. Consider if the patient is on anticoagulants
and also Consider comorbidities since pt will likely be elderly (HTN, CAD, CKD, obesity, DM)
What are specific intraoperative anesthetic considerations for TURP procedure? select 2.
A. supine position
B. should provide local anesthesia
C. lithotomy position
D. blood loss may be up to 3Ls
E. watch out for TUR syndrome
C. Lithotomy
E. TUR syndrome
also:
* General/ SAB (textbook: perform a SAB)
* Possible transfusion (EBL is 100-200cc though..)
The reason why you want to perform a SAB for a TURP is to assess for TUR Syndrome. You can assess when a patient begins to become confused versus being under general anesthesia. (left from last yr’s class)
What is TUR syndrome?
A. symptoms of hypernateria d/t water intoxication
B. hypovolemic hyponatremia
C. excessive volume expansion through the venous sinuses causing dilutional hyponatremia
D. hypovolemic water intoxication
C. Excessive volume expansion through venous sinuses from irrigation fluid used during TURP causing dilutional hyponatremia
Symptoms of hyponatremia r/t hypervolemic water intoxication!
What are CNS and EKG changes with a serum Na+ level of 120 mEq/L?
CNS changes: Confusion, Restlessness
EKG changes: Widening of QRS
What are CNS and EKG changes with a serum Na+ level of 115 mEq/L?
CNS changes: Somnolence, Nausea
EKG changes: Elevated ST segments, Widened QRS
What are CNS and EKG changes with a serum Na+ level of 110 mEq/L?
ur screwed
CNS changes: Seizure, Coma, Death
EKG changes: VT / V-fib
What are the 4 types of irrigants used in TURP?
- Saline
- Glycine - metabolized in liver to ammonia
- Water - intravascular hemolysis
- Sorbitol (sugar alcohol)
which irrigants used during TURP will cause volume overload? Select 2.
A. glycine
B. water
C. saline
D. sorbitol
E. LR
F. 0.45 NS
C. saline (messes w electrical current if using monopolar cautery)
D. sorbitol (sugar alcohol, metabolized to CO2 and fructose)
What is the irrigation rates used during TURP procedures?
How fast can the venous sinuses absorb irrigation fluid during a TURP?
- Irrigation rate: 300 ml/min
- Absorption rate: 20 to 200 ml/min
Fill in the blank:
Greater than ____ of irrigation fluid absorption is usually required for TUR syndrome.
A. 500 mL
B. 1 L
C. 2000 mL
D. 4 L
C. Greater than 2 Liters of absorption is usually what causes TUR syndrome.
keep surgery under 1 hr!! especially if higher rates of irrigation
How do you prevent TUR syndrome?
A. suspend irrigating fluid > 30 cm above the table
B. limit resection time to 1 hr
C. preoperative hydration to prevent hypotension
D. put patient in trendelenberg
B. Limit resection time to 1 hour!!
and Suspend irrigation fluid less than 30 cm above the table (so that fluid doesn’t just flood in super quick)
Also:
Treat hypotension for SAB with vasopressors; NOT IVF.
What is the tx for mild (Na > 120) TUR Syndrome?
A. Fluid restriction and loop diuretics
B. LR administration and loop diuretics
C. D5W and loop diuretics
D. Fluid restriction and 3% hypertonic solution
A. For Mild symptoms (Na > 120): Fluid restriction and Loop diuretics
Also:
* ABC’s
* terminate the procedure ASAP
* Consider invasive lines…for cardiovascular instability
What do you wanna give for Severe symptoms (Na < 120) of TUR syndrome?
3% (hypertonic) IV saline!
ABCs, probably want central line, art line, all the good stuff
What are anesthetic considerations for a robotic prostatectomy? select 2.
A. SAB or epidural
B. insertion of an arterial line
C. insertion of a central line
D. neosynephrine drip instead of fluids
B. Insertion of an arterial line (we want to watch the blood pressure d/t to being in tberg).
D. Phenylephrine drip; LIMIT IV fluids
What is a nephrectomy?
- Surgical removal of a kidney, performed to treat several kidney diseases.
What are the 3 types of nephrectomies?
- Simple: Irreversible non-malignant disease (autoimmune), trauma, congenital disease (Polycystic Kidney disease)
- Radical: Renal cell carcinoma, kidneys and adrenal glands removed
- Donor
Nephrectomies are commonly associated with what condition?
A. CAD
B. ESRD
C. HTN
D. all of the above
D. all of the above
* CAD
* CRI/ESRD
* HTN
Considering the kidney is very vascular, what are 2 considerations before taking the patient to OR for his nephrectomy? select 2
A. require lasix preop
B. type/screen or type/cross
C. SCIP antibiotics are given post-op
D. will not require anxiolytics
E. 2 large bore IVs
B. Type/Screen or Type/Cross
E. 2 large bore IV
And also:
* Anxiolytics
* SCIP
What must you have available to administer for a nephrectomy? select 3.
A. esmolol
B. blood with rapid transfusion set up
C. nitrous
D. mannitol
E. albumin
F. NS bolus
B. Blood, Rapid transfusion set up
D. mannitol
E. colloids (albumin or dextran!)
and furosemide
Which kidney has a longer ureter and longer vascular supply?
- Left Kidney
left kidney preferred from living donor
left from last yrs class
What arteries and veins do transplanted kidneys attach to?
- Transplanted kidneys are attached to the common iliac vein and artery
In what order does the surgeon re-anastomose the ureter, vein and artery in a kidney transplant?
- Re-anastomose the vein first, then the artery, then the ureter.
What fraction of all nephrectomies are living donor nephrectomies?
- one-third
One of the benefits of receiving a kidney from a living donor as opposed to a DBD/DCD is:
A. longer wait times
B. less likely to reject living donor kidney
C. decreased ischemic times
D. urine output is not as decreased as with DBD/DCD
C. Decreases ischemic times
also:
* No physiological alterations compared to Donations after brain death or cardiac death donor.
* Waiting times avoided
What would disqualify someone from being a living donor of a kidney? select 2.
A. HIV
B. HTN
C. liver disease
D. CAD
A. HIV
C. Liver Disease
also DM and cancer
must also be Healthy and have Two Kidneys
What are some intraoperative considerations for a living donor about to have a nephrectomy? select 2.
A. aggressive isotonic hydration of 10-20 mL/kg/hr
B. right kidney preferred
C. requires regional anesthesia only
D. 5000 u of heparin
E. furosemide, bumetanide, or mannitol to maintain 2 mL/kg/hr
F. versed only for patients appearing anxious in preop
A. Aggressive isotonic hydration (10-20 ml/kg/hr)
D. Kidney needs low-level anticoagulation = 5000 U of heparin
E. Need diuresis = Furosemide, mannitol to maintain 2 ml/kg/hr of UOP
will need to reverse heparin once kidney is out = 50 mg Protamine
What 3 neurological signs will appear with a DBD, usually as a result of catastrophic ICP elevation?
A. miosis
B. HTN
C. bradycardia
D. widened pulse pressure
E. dilated pupils
F. hypothermia
B. HTN
C. bradycardia
D. widened pulse pressure
AKA Cushing’s sign = Catastrophic ICP elevation
will ask her about this because cushing’s triad is defined by irregular respirations, not necessarily HTN.
What are the cardiac alterations that eventually occur in a DBD?
A. CV collapse
B. afib
C. 2nd degree heart block
D. electrolytes cause tall peaked T wave
A. CV collapse (catecholamines run out, massive dilation)
initially: Massive release of catecholamines!
acute MI has 40% occurrence
What pulmonary instability/alterations can occur with a DBD?
A. TRALI
B. slow, shallow breathing
C. neurogenic pulmonary edema
D. kussmaul respirations
C. Neurogenic pulmonary edema
and SIRS!
A Donor after Brain Death (DBD) will have dysfunction of the hypothalamus and pituitary systems. What may this look like?
A. difficulty thermoregulating
B. low TSH
C. elevated blood glucose
D. electrolytes appear normal
E. increased insulin production
A. Thermoregulation will be all over the place
C. elevated blood glucose
Also: hormones, insulin, electrolytes will all be jacked up…and DIC
what are anesthesia considerations specific for the cadaver donors? select 3.
A. require more volatiles than living donor
B. avoid glucose containing solutions
C. give steroids to help immune response
D. no esmolol
E. fluid restriction
F. fluid resuscitate with crystalloids + prbc’s
B. Avoid glucose-containing solutions, can metabolize and become a hypotonic solution
C. Steroids to attenuate immune response (in recipient)
F. Fluid resuscitation with crystalloids and PRBC’s
Also:
* Don’t need anesthetics (b/c brain dead) but need stabilization until retrieval
* Maintain hemodynamics with short-acting agents (use esmolol, cardene gtt) and vasopressors
* If significant bradycardia not responsive to anticholinergics…use isuprel (isoproterenol)
For cadaver donor, if significant bradycardia is not responsive to anticholinergics, what should we give?
A. neosynephrine
B. dopamine
C. levophed
D. isoproterenol
D. isuprel (isoproterenol)
what are our protective ventilation settings for a DCD?
A. 3-5 mL/kg of IBW
B. 6-8 mL/kg of IBW with 5 cm H2O PEEP
C. 3-5 mL/kg with 5 cm H2O PEEP
D. 6-8 mL/kg of IBW; no PEEP required
B. PEEP/lung protective ventilation: 6-8 ml/kg of ideal body weight and 5-10cm PEEP
Donor Management Goals:
CVP
4-10 mmHg /
6-8 mmHg for lung transplant
Donor Management Goals:
MAP
60-120 mmHg
Donor Management Goals:
PaO2
> 300 mmHg on 5cm H2O PEEP on 100% O2
Donor Management Goals:
Urine Output
Greater than 1 mL/kg/hr
Donor Management Goals:
Sodium
135-160 mEq/L
Donor Management Goals:
Glucose
less than 150 mg/dL
Donor Management Goals:
Ejection Fraction
> 50%
Donor Management Goals:
Hemoglobin
> 9 g/dL
Donor Managment Goals:
Pressors?
1 and low dose
During a kidney transplantation, what is the ischemic time for the kidney?
- 48-72 hours
What are the more important preoperative questions that the CRNA should consider for their kidney transplant recipient? select 2.
A. are they on lasix at home? did they take it this morning?
B. what was their last blood sugar? are they on any insulin?
C. what was their last PFTs?
D. when was their last dialysis? and whats the K+ now?
B. Diabetic (blood sugar, insulin)
D. Need to know last dialysis and K+ level
Also:
* 40% have CAD, and most have HTN (EKG, Heart Cath)
* If PCKD, is nephrectomy concurrent? (Consider positioning)
what are specific intraop considerations for kidney transplantation?
A. consider using nimbex as NMBD
B. might have to prone in middle of case so prepare to reposition
C. keep intubated until they’re in ICU
D. if placing a CVP/art line, maintain absolute sterility
E. give anti-thymocyte to prevent rejection
F. will be in left lateral position to insert kidney on left side
A. Consider cisatracurium (b/c renal protective!)
D. CVP/art line…..STERILE. Pt will be on immunosuppressants.
F. Steroids, mannitol, lasix, bumex, antithymocyte, albumin
* GETA, may use Anectine if K+ appropriate
* Supine; watch AV access
* Donor anastomoses to recipient (vein, artery, ureter)
* Extubate on table…to ICU (D/C next day)
T/F:
An anti-thymocyte is an infusion of rabbit-derived antibodies against human T cells to prevent/treat sepsis after transplantation.
False: An anti-thymocyte is an Infusion of rabbit-derived antibodies against human T cells to prevent/treat acute rejection.
Cytokine release syndrome can occur in response to anti-thymocyte. What s/sx may we see? select 2.
A. N/V
B. hyponatremia
C. high-grade fever (> 39 C) and chills
D. petechiae
E. possibly rigors
F. hives
C. high grade fever (>39 C) and chills
E. possibly rigors
Tx: steroids (methylprednisolone aka solumedrol), diphenhydramine (Benadryl) 25–50 mg, acetaminophen 650 mg
