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Principles I* > E3- GU Procedures > Flashcards

E3- GU Procedures Flashcards

1
Q

6 Indications for Urological Surgery

A

Direct visualization of urethra, bladder, ureter, kidney
* Biopsies/evaluate bleeding
* Retrograde pyelography
* Laser/retrieve stones
* Remove/treat stricture
* Resect masses

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2
Q

%%%

List the structures of the genitourinary system from the top to bottom.

A
  • Kidney
  • Ureter
  • Bladder
  • Urethra
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3
Q

What position will the patient be in for Urological Surgery?

A
  • Lithotomy
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4
Q

In the Lithotomy position, the stirrups can cause what type of nerve injury?

A
  • Peroneal Nerve Injury
  • Femoral Nerve Injury
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5
Q

What other problems can occur besides nerve injuries in the Lithotomy position?

A
  • Skin breakdown d/t stirrup pressure
  • Hip dislocation
  • Back strains
  • Vessel compression (DVT, Compartment Syndrome)

Remember to move both legs simultaneously to prevent torsion and injury to lower spine

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6
Q

What lab is the best measure of glomerular function?

A
  • GFR
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7
Q

What is normal GFR?
When will patients become symptomatic?

A
  • 125 mL/min
  • Asymptomatic until a 50% drop
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8
Q

What will be the result of moderate GFR insufficiency?

A
  • ↑ BUN/Creat
  • Anemia
  • Decreased energy
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9
Q

What will be the result of severe GFR insufficiency?

A
  • Profound uremia (high levels of waste product in the blood)
  • Acidemia
  • Volume overload
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10
Q

%%%

What is BUN?

A
  • Blood Urea Nitrogen
  • BUN measures the amount of nitrogen in the blood that comes from the waste product urea.
  • Urea is produced when the body breaks down proteins from the food we eat.
  • The liver then processes this nitrogen into urea, which is eventually eliminated from the body through urine.
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11
Q

What is a Normal BUN?

A
  • 8-18 mg/ dL
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12
Q

What will influence the BUN level?

A
  • Exercise
  • Steroids
  • Dehydration
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13
Q

BUN will not be elevated in the kidney disease until GFR is ________% of normal.

A
  • 75%
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14
Q

%%%

What is Creatinine?

A
  • Creatinine is a waste product that comes from muscle metabolism.
  • It is produced at a relatively constant rate and is filtered out of the blood by the kidneys, then excreted through urine.
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15
Q

What is normal Creatinine? Varies with?

A
  • 0.8 - 1.2 mg/dL
  • Varies with age and gender
  • Higher in men d/t more muscle mass
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16
Q

What are 6 considerations during the preoperative evaluations of patients with Chronic Renal Failure?

A
  • Hypervolemia = ↑Na, ↑H2O
  • Acidosis = ↓ production of ammonia, ↑ Anion Gap
  • Hyperkalemia = normally managed … precipitated by hemorrhage, met acidosis
  • HTN d/t RAAS
  • Cardiac/Pulmonary Symptoms = arthersclerosis, pulm edema, vent hypertrophy
  • Hematologic Symptoms
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17
Q

What type of anemia with CRF pts have? what is abnormal?

A
  • normochromic (color) , normocytic (size) , iron defecient anemia
  • abnormal :: plt aggregation + prothrombin consumption
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18
Q

Because most anesthetic drugs are lipid soluble in a non-ionized state, termination doesn’t depend on _________.

A
  • Renal Excretion

Metabolite of these drugs are excreted as water-soluble compounds

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19
Q

What are 7 drugs of concern for patients with Renal Insufficiency?

A
  • Drugs that are highly ionized and eliminated unchanged in urine
  • Muscle relaxants (pancuronium)
  • H2 antagonists
  • Cholinesterase inhibitors (neostigmine)
  • Thiazide diuretics
  • Digoxin
  • Many antibiotics
  • Active metabolites of opioids (morphine/meperidine/ketamine/midazolam)
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20
Q

%%%

What is the active metabolite of morphine?

A
  • Morphine-6-glucuronide
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21
Q

Renal Protection strategies

A

Pts w/ moderate RI - cardiac sx + AKI (sepsis, crush, burn, nsaids)
* hydration
* adequate RBF
* NOT helpful = mannitol, low dose dopamine , fenoldopam , loop d, bicacrb gtt

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22
Q

Only renal protection strategy proven to work

A

N-Acetylcysteine (dye injuries)

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23
Q

Mortality rate of AKI?

A

50%

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24
Q

What are examples of endoscopic evaluations (scope procedures) of the lower urinary tract?

A
  • Through urethra = urethroscopy
  • Through bladder = cystoscopy
  • Through ureteral orifice = ureteroscopy
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25
What are the two types of scopes used for urological procedures?
* Flexible * Rigid (this scope NOT into ureter, it will stop in the bladder) ## Footnote Scope hooked to irrigation system Guid Wire is inserted through scope for catheter and instruments
26
Purpose of a urethroscopy/cystoscope.
* **Visualize** the urethra and/or bladder d/t urinary symptoms (Pain, burning, hematuria, difficult urination.) * **Diagnose and Treat** a lesion or stricture (dilate stricture, treat cystitis, stent placement, resect tumors).
27
The procedure of choice for mid/distal ureter or bilateral stones.
* Ureteroscopy (flexible scope) ## Footnote Can incorporate **laser** technology
28
What percentage of men and women lifetime will experience ureter stones? What is the recurrence percentage? Stones contain ______ and are _____.
* Men: 10% * Women: 5% * Recurrence: 50% * Calcium ,, radiopaque
29
Ureter stones are diagnosed using _______, _______, and ________.
* CT * KUB X-RAY * IVP (Intravenous Pyelogram)
30
Complications of ureteroscopy are low. What is the percentage for perforation? What is the percentage of stricture formation?
* Perforation: 5% * Stricture formation: <2%
31
What are some medical therapy for ureter stones?
* MET (Medical Expulsive Therapy) * NSAIDs * Aggressive Fluid intake * **CCB and alpha blocker**s to vasodilate - relax ureter * Surgery
32
What are 3 choices for surgery for ureter stones?
* Stone basket vs. Laser (preferred) - uteroscopy * Shock Wave Lithotripsy * Percutaneous nephrolithotomy (least preferable)
33
Shock wave Lithotripsy is best suited for __________ intranephric stones.
* small/medium
34
What is the risk for Shock Wave Lithotripsy (SWL)?
* kidney injury (trauma from pressure) * sub-capsular hematoma
35
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
36
What are ABSOLUTE contraindications to SWL?
* Bleeding disorder/ anticoagulants * Pregnancy
37
5 RELATIVE contraindications to lithotripsy
* Large calcified aortic/renal aneurysms * Untreated UTI * Obstruction distal to the renal calculi * Pacemaker, ICD, neuro-stimulate * Morbid obesity
38
Preoperative anesthetic considerations for SWL, stone basket, or laser therapy.
* Single PIV * Consider anxiolytics * Appropriate ABX within 1 hour "cut time" * **Iodine Allergy** - pretreat with benadryl
39
Intraoperative anesthetic considerations for SWL, stone basket, or laser therapy.
* Local vs. General (most people will be general) * LMA vs ETT * Minimal narcotics * Consider antiemeticc * **Eye covering for laser ** * **Lead** for providers | *PACU postop*
40
What procedure will be indicated for **large** intranephric stone removal?
* Percutaneous Nephrolithotomy
41
Describe a percutaneous nephrolithotomy.
* Minimally-invasive procedure to remove stones from the kidney by a small puncture wound through the skin. * The procedure will** require initial stent placement** of ureteral stents to prevent obstruction as the fragment passes * Uses lg amt **fluoroscopy** * **Transurethral Resection syndrome** possible
42
Preoperative anesthetic considerations for percutaneous nephrolithotomy.
* Single PIV * Consider anxiolytics * Appropriate ABX within 1 hour "cut time"
43
Intraoperative anesthetic considerations for percutaneous nephrolithotomy. Position? NMBD?
* General ETT * Short NMBD's * **Lateral** position (bean bag, pillows) * **Lead** apron for provider * **Eye covering** for laser (document!)
44
What is an orchiectomy?
* one or both testicles are removed. * Almost always **bilateral** * Spermatic cord is clamped, cut, and sutured * **metastatic prostate cancer**
45
What is a Hydrocelectomy?
* remove a hydrocele. * A hydrocele is a fluid-filled sac inside the scrotum. * **Wall of hydrocele excised and edges sutured to prevent recurrence.**
46
Testicular torsion must be performed within ____ hours to prevent **irreversible ischemia**.
* 6 hours
47
What are the reasons for circumcision in older males?
* Phimosis (tight foreskin) * Penile/ prostate cancer risk
48
What is hypospadias?
* Birth defect in boys **opening of the urethra** is not located at the tip of the penis.
49
What is a Penectomy?
* Removal of **squamous cell carcinoma on the penis or inguinal lymph node**.
50
What population group would seek a penile prosthesis discussed in the lecture? Special considerations?
* Diabetic patients * Spinal cord injury patients * Infection risk !!
51
Anesthetic considerations for scrotal and penile operations.
* Preop anxiolytics * General: ETT vs LMA * **Supine** * **Penile Block :: (S2-S4) = pudendal nerve** * **SCIP** (take care with **prosthesis** touching skin before insertion) * Manipulation of genitals ---vagal **bradycardia**, have glycopyrrolate ready
52
What is a Cystectomy?
* Surgical removal of all or part of the urinary bladder.
53
What are the indications for cystectomy?
* Simple-**benign** conditions (hemorrhagic cystitis, radiation cystitis) * Radical - **malignant** conditions (bladder cancer, includes removal of ureters, prostate, uterus, ovaries) * Requires **ileal conduit or bladder substitution**
54
Preoperative anesthetic considerations for cystectomy.
* Risk factors for CAD or pulmonary disease, CXR? (older patients) * Anticoagulant use. EKG? * **Bowel prep**
55
Intraoperative anesthetic considerations for cystectomy.
* GETA, SAB, epidural * Supine * SCIP
56
What are 3 common complications of cystectomy?
* Blood loss: up to 3L --- 1-2 PIV, type and crossmatch blood * 3rd space losses d/t open belly * Hypothermia --- prepping lg area
57
What is a TURP?
* Transurethral Resection of Prostate * Surgical procedure that involves cutting away a section of the prostate using a laser or electrocautery. * Usually done on elderly patients to treat **BPH, the gold standard**
58
What is the estimated blood loss of a TURP?
* 100-200 mL
59
What comorbidities will patients receiving a TURP procedure have?
* Patients are generally in their 30-50's * Obesity * HTN * Hyperparathyroidism * Chronic Renal Insufficiency * DM * Paraplegia
60
Preoperative anesthetic considerations for TURP?
* Consider comorbidities * Consider if the patient is on anticoagulants * Large bore IV (18G or 16G)
61
Intraoperative anesthetic considerations for TURP?
* General/ SAB (**textbook: perform a SAB**) * **Lithotomy** * Possible transfusion * TUR syndrome ## Footnote 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.
62
What are anesthetic considerations to take into account for robotic prostatectomy?
* Insertion of an arterial line (we want to watch the blood pressure d/t to lack of fluid). * Phenylephrine drip * LIMIT IV fluids
63
What is TUR syndrome?
* Symptoms r/t hypervolemic water intoxication * Excessive volume expansion through venous sinuses * >> Hyponatremia | D/t Irrigating fluid!
64
What are CNS and EKG changes with a serum Na+ level of 120 mEq/L?
CNS changes: Confusion, Restlessness EKG changes: Widening of QRS
65
What are CNS and EKG changes with a serum Na+ level of 115 mEq/L?
CNS changes: Somnolence, Sleepy, Nausea EKG changes: Elevated ST segments, Widened QRS
66
What are CNS and EKG changes with a serum Na+ level of 110 mEq/L?
CNS changes: Seizure, Coma, Death EKG changes: V-tach, V-fib
67
What are the types of irrigants used in TURP?
* Saline- volume overload, current dispersion with monopolar cautery * Glycine- metabolized in liver to ammonia * Water- intravascular hemolysis * Sorbitol- metabolized to CO2 and fructose, volume overload
68
What is the irrigation rate for a TURP? What is the absorption rate of irrigation fluid for a TURP?
* Irrigation rate: 300 ml/min * Absorption rate: 20 to 200 ml/min
69
Greater than _______ (volume) of irrigation fluid absorption is usually required for TUR syndrome.
* 2 Liters
70
How do you prevent TUR syndrome? 3
* Limit resection time to **1 hour** * Suspend the irrigation fluid **less than 30 cm** above the table * Treat hypotension for SAB with vasopressors NOT IVF
71
Treatment of TUR Syndrome (Mild vs Severe)
* ABC’s * Stop the procedure * Consider invasive lines…for cardiovascular instability * For Mild symptoms (Na > 120): **Fluid restriction and Loop diuretics** * Severe symptoms (Na < 120): **3% IV saline**
72
What is a nephrectomy?
* Surgical removal of a kidney, performed to treat several kidney diseases.
73
How many nephrectomies are performed each year? Complication rate?
* 50,000 nephrectomies/yr * 20% post-op compilation rate: mortality, peritonitis, acute renal failure, etc.
74
What are the types of nephrectomy procedures?
* Simple: Irreversible non-malignant disease (autoimmune), trauma, congenital disease (Polycystic Kidney disease) * Radical: Renal cell carcinoma, kidneys and adrenal glands removed * Donor
75
Nephrectomies are commonly associated with these conditions.
* CAD * CKD / ESRD * HTN
76
Preoperative anesthetic considerations for nephrectomy.
* Anxiolytics * SCIP * Type/Screen or Type/Cross * 2 large bore IV
77
Intraoperative anesthetic considerations for nephrectomy.
* GETA: avoid nitrous * Consider an arterial line * Consider a central line: **Ipsilateral** to the surgical site * Consider regional anesthesia for postop pain * Have these items available: Colloids, Blood, Rapid transfusion set up, mannitol, furosemide
78
Which kidney has a long ureter and longer vascular supply?
* Left Kidney
79
What arteries and veins do transplanted kidneys attach to?
* Transplanted kidneys are attached to the common iliac vein and artery
80
Do you re-anastomose the vein, artery, or ureter first in a kidney transplant?
* Re-anastomose :: Vein >> artery >> ureter
81
What fraction of all nephrectomies are living donor nephrectomies?
* 1/3
82
What are the benefits of receiving a kidney from a living donor?
* No physiological alterations compared to Donations after brain death or cardiac death donor. * Waiting times avoided * Decreases cold ischemic times
83
What are the parameters of being a living donor?
* Healthy * Two Kidneys * No DM, HIV, Liver Disease, Cancer
84
Anesthesia Considerations for the Living Kidney Transplantation.
* Similar to simple nephrectomy (anesthesia-wise) * Starts a couple of hours before recipient * Left kidney preferred * **Aggressive isotonic hydration (10-20 ml/kg/hr)** * Kidney needs low-level anticoagulation (5000 U of heparin) * Furosemide, mannitol to **maintain 2 ml/kg/hr** * Protamine reversal (50 mg)
85
What neurological instability will occur with brain death? 2
* Cushing’s sign: HTN, bradycardia, wide pulse pressure * Catastrophic ICP elevation
86
What cardiac instability will occur with brain death? 3
* Massive release of catecholamines * Acute MI * Cardiovascular collapse (catecholamines run out, massive dilation)
87
What pulmonary instability will occur with brain death? 2
* Neurogenic pulmonary edema * SIRS
88
What metabolic instability will occur with brain death?
* Dysfunction of the hypothalamus and pituitary systems * Thermoregulation, hormones, insulin, electrolytes, DIC
89
Anesthesia Considerations for the Cadaver Donors.
* Don’t need anesthetic….need stabilization until retrieval * Maintain hemodynamics with **short-acting** agents (cardene, esmolol, volatiles) * Significant bradycardia not responsive to anticholinergics…use **isuprel** * Fluid resuscitation with **crystalloids and PRBC’s** * Avoid glucose-containing solutions, can metabolize and become a hypotonic solution * PEEP/lung protective ventilation: **6-8 ml/kg** of ideal body weight and **5-10cm PEEP** * **Steroids** to attenuate immune response (in recipient)
90
Donor Management Goals: CVP
* 4-10 mmHg * 6-8 mmHg for lung transplant
91
Donor Management Goals: MAP
* 60-120 mmHg
92
Donor Management Goals: PaO2
* >300 mmHg on 5cm PEEP on 100% O2
93
Donor Management Goals: PaCO2
* 35-45 mmHg
94
Donor Management Goals: ABG pH
* 7.35-7.45
95
Donor Management Goals: Urine Output
* Greater than 1 mL/kg/hr
96
Donor Management Goals: Sodium
* 135-160 mEq/L
97
Donor Management Goals: Glucose
* < 150
98
Donor Management Goals: Ejection Fraction
* >50%
99
Donor Management Goals: Hemoglobin
* > 9
100
Ischemic time for kidney
* 48-72 hours
101
What happens to the donor kidney during ischemia?
* Lack of O2 * Depletion of ATP/glycogen * Failure of Na/K Pump * Increase intracellular sodium....edema
102
What are preop evaluations for the kidney recipient?
* Need to know last dialysis and K+ level * Diabetic (blood sugar, insulin) * 40% have CAD, and most have HTN (EKG, Heart Cath) * If PCKD, is nephrectomy concurrent? (Consider positioning)
103
Intraoperative consideration for kidney transplantation.
* GETA, may use Anectine if K+ appropriate * Consider **cisatracurium** * **Supine**; watch AV access * CVP/art line…..**STERILE** * Donor anastomoses to recipient (vein, artery, ureter) * Steroids, mannitol, lasix, bumex, antithymocyte, albumin * Extubate on table…to ICU (D/C next day)
104
What is an anti-thymocyte?
* Infusion of rabbit-derived antibodies against human T cells to prevent/treat acute rejection
105
What is the side effect of an anti-thymocyte? Treatment?
* Cytokine release syndrome: high-grade fevers (over 39C), chills, and possibly rigors. * Treatment: steroids (normally methylprednisolone), diphenhydramine 25–50 mg, acetaminophen 650 mg
106

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