Elimination & Detox 2: Renal Dz & Anesthesia Flashcards
1
Q
3 main functions of KIDNEY?
A
- FILTRATION to REMOVE METABOLIC PDTS/TOXINS from BLOOD & EXCRETE IN URINE
- MAINTENANCE of HOMEOSTASIS for BODY FLUIDS, ELECTROLYTE & ACID-BASE BALANCE
- SECRETION OF HORMONES
2
Q
HORMONES secreted by the kidney help achieve… (4)
A
- ERYTHROGENESIS (making RBCs)
- CALCIUM METABOLISM
- REGULATION OF BLOOD PRESSURE
- REGULATION OF BLOOD FLOW
3
Q
kidney requires a HIGH amount of ____ because….
A
OXYGEN, because 25% of ALL CO IS USUALLY DIRECTED TO IT
4
Q
AUTOREGULATION of the kidney..
= definition?
3 benefits?
A
= can INDEPENDENTLY MAINTAIN RENAL BLOOD FLOW in a NARROW RANGE DESPITE FLUCTUATIONS IN SYSTEMIC BP
3 benefits?
1. maintenance of HIGH OXYGEN DELIVERY during STATES OF LOW PERFUSION
- helps STABILIZE FILTERED LOAD/GFR IS AT STEADY RATE
- PROTECTS GLOMERULAR CAPILLARIES from HIGH SYSTEMIC PRESSURE
5
Q
PROCESS of AUTOREGULATION by kidneys? (4)
A
- AFFERENT arteriole carries fluid from SYSTEMIC vasculature INTO GLOMERULUS
- as PRESSURE increases from FLUID IN AFFERENT arteriole, it STRETCHES THE WALL & NON-SELECTIVE CATION CHANNELS will OPEN IN RESPONSE
- once channels open, RELEASES CALCIUM to cause CONTRACTION OF SMOOTH MUSCLE IN VESSEL WALL
- overall, can REDUCE BLOOD FLOW GOING TO KIDNEY IN HIGH PRESSURE STATES
6
Q
what is the AUTOREGULATORY RANGE of the KIDNEYS?
what happens if we go ABOVE this range?
what happens if we go BELOW this range?
A
60 - 150 mmHg MAP
if we go >150 mmHg, AUTOREGULATION LOSES ABILITY TO CONTROL FLOW, see increase in FLOW & PRESSURE
if we go <60 mmHg, KIDNEYS CANNOT MAINTAIN BLOOD FLOW & OXYGEN DELIVERY
7
Q
METABOLIC CHANGES that occur with RENAL IMPAIRMENT… (5)
A
- ABILITY OF KIDNEYS to EXCRETE WATER & SODIUM can be impaired
- REGULATION of ELECTROLYTE HOMEOSTASIS
- underlying METABOLIC ACIDOSIS
- HYPOALBUMINEMIA
- INABILITY to PROCESS WASTE causes them to ACCUMULATE
8
Q
what is the BIGGEST ELECTROLYTE RISK regarding KIDNEYS when UNDER GA? why?
A
HYPERKALEMIA, which can induce LETHAL CARDIAC ARRHYTHMIAS from ALTERING REPOLARIZATION OF MYOCARDIAL CELLS
9
Q
HEMATOLOGIC changes in RENAL IMPAIRMENT… (2)
A
- DECREASED PRODUCTION of EPO –> NON-REGEN ANEMIA (decreased production)
- ABNORMAL PLATELET FUNCTION, NOT REPRESENTED ON PT/PTT or ANY CBC; just BLEEDS A LOT
10
Q
5 CLINICAL SIGNS from RENAL DZ…
three are GI, two are more general
A
- NAUSEA
- VOMITING
- INAPPETENCE
- DEHYDRATION
- DELAYED WOUND HEALING
11
Q
4 CARDIOVASCULAR changes from RENAL IMPAIRMENT? (last one has 3 subs)
A
- CHRONIC ARTERIAL HYPERTENSION
- shift in AUTOREGULATORY RANGE
- RENAL INJURY & DISEASE PROGRESSION from HYPERTENSION (outside auto regulatory range)
- LONG-TERM ARTERIAL HYPERTENSION can cause STRUCTURAL CHANGES IN MYOCARDIUM such as…
–> LEFT VENTRICULAR HYPERTROPHY
–> DIASTOLIC DYSFUNCTION
–> VALVULAR INSUFFICIENCY
12
Q
4 RESPIRATORY CHANGES with RENAL IMPAIRMENT…
GENERALLY…
A
- PULMONARY EDEMA & PLEURAL EFFUSION from VOLUME OVERLOAD
- DECREASED FUNCTIONAL RESIDUAL CAPACITY (from PULMONARY EDEMA/PLEURAL EFFUSION)
- DECREASED PULMONARY COMPLIANCE (from PULMONARY EDEMA/PLEURAL EFFUSION)
- INCREASE in VENTILATION-PERFUSION MISMATCH (from PULMONARY EDEMA/PLEURAL EFFUSION)
GENERALLY, we don’t tend to see many RESPIRATORY CHANGES with renal impairment
13
Q
DRUGS & RENAL IMPAIRMENT…
drugs that undergo RENAL ELIMINATION…
what 3 CBC findings contribute to a REDUCTION in PROTEIN-BINDING? what is the significance of this?
____ ___ may INCREASE the ____ of ____ of HYDROPHILIC drugs
____ can increase the ____ of the ____ ____ ____
A
drugs that undergo RENAL ELIMINATION may ACCUMULATE with renal impairment
3 CBC findings that REDUCE PROTEIN-BINDING?
1. HYPOALBUMINEMIA
2. AZOTEMIA
3. ACIDEMIA
–> PROTEIN-BINDING DRUGS may be INEFFECTIVE in renal dz patients
FLUID RETENTION may INCREASE the VOLUME of DISTRIBUTION of HYDROPHILIC drugs
UREMIA can increase the PERMEABILITY of the BLOOD BRAIN BARRIER
14
Q
giving BENZODIAZEPINES to patients with RENAL DZ? (3)
hint: end with how we should administer them
A
- BENZODIAZEPINES are HIGHLY PROTEIN-BOUND drugs
- so NORMALLY only a SMALL % of this dose SITS IN CIRCULATORY SYSTEM/BIOAVAILABLE for use
- but when DISEASED, MORE DRUG IS AVAILABLE TO BIND TO RECEPTOR & likely need DOSE REDUCTION
15
Q
if BBB is ALTERED due to UREMIA in patient with kidney dz, what is an ANESTHETIC CONSIDERATION we should have? (two)
A
- ANESTHETIC DRUGS can ACTIVATE or INHIBIT RECEPTORS in CNS & usually CROSS BBB
- if BBB is MORE PERMEABLE to these drugs, MIGHT WANT TO GIVE A REDUCED DOSE
16
Q
2 main goals for ANESTHETIC MANAGEMENT for patients with RENAL DZ?
A
- MINIMIZE RISK of FURTHER KIDNEY INJURY via…
–> MAINTAIN ADEQUATE RENAL PERFUSION
–> REDUCE exposure to NEPHROTOXIC COMPOUNDS - ID & OPTIMALLY MANAGE MODIFIABLE RISK FACTORS
17
Q
NSAIDs & renal dz patients?
A
NSAIDs are NEPHROTOXIC COMPOUNDS
18
Q
PRIOR to anesthesia for KIDNEY DZ patients, we should…
why?
A
STAGE THEIR KIDNEY DISEASE
because we have HUMAN studies that show DIRECT RELATIONSHIP BETWEEN CKD SEVERITY & PERIOPERATIVE MORBIDITY & MORTALITY
19
Q
most common grading system for kidney dz in DOGS/CATS?
what 3 parameters does it examine?
A
INTERNATIONAL RENAL INTEREST SOCIETY for both AKI and CKD
3 parameters?
1. SERUM CREATININE & its TREND (don’t want to see it change much/increasing)
2. PROTEINURIA
3. BLOOD PRESSURE
20
Q
if SERUM CREATININE is trending towards INCREASING, this can suggest…
A
PROGRESSION OF RENAL DZ
21
Q
if an animal has STABLE RENAL DZ, how soon prior to Sx should we perform bloodwork?
if UNSTABLE, then how soon?
A
2 WEEKS to a MONTH BEFORE Sx
if UNSTABLE, then do b/w MUCH CLOSER TO PROCEDURE
22
Q
CBC/Chem findings for RENAL DZ that we should run PRIOR to Sx? (2)
A
- COMPLETE BLOOD COUNT, look for ANEMIA & HEMOCONCENTRATION
- CHEMISTRY –> BUN, CREATININE, ACID-BASE balance, ELECTROLYTES
23
Q
if we’re concerned that a patient with RENAL DZ also has CARDIOVASCULAR INSTABILITY, what 3 diagnostics should we look into performing?
what ELECTROLYTE value commonly found with RENAL DZ may indicate this?
A
- TFAST
- ECHOCARDIOGRAM
- ECG
HYPERKALEMIA can indicate this!
24
Q
if we’re concerned that a patient with RENAL DZ also has VOLUME OVERLOAD, what 2 diagnostics should we look into performing?
A
- THORACIC RADS
- TFAST
25
TRUE/FALSE
PATIENTS with RENAL DZ COMMONLY have COEXISTING DISEASES, so be THOROUGH ON PE.
TRUE
26
in patients with RENAL DZ, RISK ASSESSMENT & MITIGATION is necessary, why?
because PATIENTS WITH RENAL DZ can be PRONE TO PERIOPERATIVE and POST-OP COMPLICATIONS
27
in patients with AKI, SURGERY....
SHOULD ONLY BE DONE IF IT'S LIFE-SAVING!
28
list the 5 RISK ASSESSMENT parameters PRIOR to Sx for RENAL DZ patients
OVERALL, the ___ of the procedure SHOULD...
1. ID RESOURCES to MOBILIZE if necessary
--> O2 cages, consult specialists
2. determine need for ADDITIONAL TESTING
3. ID patients that can BENEFIT FROM STABILIZATION (such as weight loss) to help IMPROVE SURGICAL OUTCOME
4. determine need for CHANGE IN PATIENT MANAGEMENT
5. FACILITATE COMMUNICATION between the TEAM
OVERALL, the VALUE of the procedure SHOULD OUTWEIGH THE RISK
29
MODIFIABLE RISK...
= definition?
what are the 7 MODIFIABLE RISKS in RENAL DZ?
= risks that we can likely REDUCE THE POTENCY OF
1. CARDIOVASCULAR INSTABILITY (hypotension & hyovolemia)
2. HYPERTENSION
3. ANEMIA
4. ELECTROLYTE DERANGEMENT (hyperkalemia)
5. EMERGENCY SURGERY
6. ACIDOSIS
7. NEPHROTOXIC MEDS (NSAIDs, some antibiotics)
30
HYPOVOLEMIA to the kidney & ANESTHETIC DRUGS? (2)
HYPOVOLEMIA can ENHANCE CARDIOVASCULAR DEPRESSANT effects of ANESTHETIC DRUGS --> so can more likely cause BRADYCARDIA/DECREASED CONTRACTILITY DURING Sx
31
if a patient comes in HYPOVOLEMIC and with RENAL DZ, what should be done PRIOR to surgery?
what should be MONITORED & why? give 5 parameters
CIRCULATORY VOLUME should be REESTABLISHED PRIOR TO ANESTHESIA to REDUCE PERIOPERATIVE RISK
however, must monitor for VOLUME OVERLOAD because with RENAL DZ, CANNOT REGULATE VOLUME IN EITHER DIRECTION
1. HR
2. RR
3. BP
4. CENTRAL VENOUS PRESSURE
5. HOW MUCH FLUID IS COMING IN VS. OUT
32
TRUE/FALSE
HYPOTENSION must be resolved prior to Sx for RENAL DZ patients, but HYPERTENSION is OK
FALSE, HYPERTENSION MUST BE CORRECTED PRIOR TO ELECTIVE PROCEDURES
33
if a patient has HYPERTENSION and undergoes Sx, then how can HYPOTENSION be more likely?
in HYPERTENSION, RENAL PERFUSION can be IMPAIRED starting at a MUCH HIGHER ARTERIAL PRESSURE, so if we wait until 60 mmHg to treat for hypotension when BELOW 80 mmHg is a problem, kidneys MIGHT HAVE ALREADY BEEN HYPOPERFUSED FOR A LONG PERIOD OF TIME at this point
34
what SHOULD we do if a patient has HYPERTENSION prior to sx?
give 2 recommendations for this treatment.
HYPERTENSION = treat with ACE INHIBITORS or something to bring down BP
2 recommendations...
1. STOP ACE INHIBITOR 12 HOURS PRIOR TO Sx
2. RESTARTED IMMEDIATELY after ANESTHESIA
35
if we have to take a HYPERTENSIVE PATIENT into EMERGENCY SURGERY, how should we handle that?
after taking the patient's MAP PRIOR to sx, can move the MINIMUM MAINTAINED BP however far above 60 mmHg that seems CLOSE to this taken MAP
36
ANEMIA during Sx in RENAL DZ patient...
is often ____ and ___-___
what parameter indicates PATIENTS EXPERIENCING REDUCED OXYGEN DELIVERY TO TISSUES? what should we do if so?
4 CLINICAL signs of REDUCED O2 delivery?
1 CBC finding for REDUCED O2 delivery?
CHRONIC, WELL-TOLERATED
HEMOGLOBIN < 7 g/dL = OXYGEN CARRYING CAPACITY MAY BE REDUCED; may want to TRANSFUSE patient prior to Sx
clinical signs?
1. FATIGUE/WEAKNESS
2. ALTERED MENTATION
3. TACHYCARDIA
4. TACHYPNEA
CBC finding?
1. LACTATE ELEVATION
37
HYPERKALEMIA in RENAL DZ & Sx...
can lead to ____ ____ ____ due to ____ ____ ____
if POTASSIUM is ____ THAN ____ mEq/L, then...
can lead to LETHAL CARDIAC ARRHYTHMIAS due to ALTERED MYOCARDIAL REPOLARIZATION
if POTASSIUM is HIGHER THAN 5.5 mEq/L, then DELAY ANESTHESIA/SURGERY even in EMERGENCIES
38
if patient is HYPERKALEMIC, what are 2 ways we can REDUCE K?
1. RESOLUTION OF RENAL INSULT (ex = unblocking obstructed cat)
2. PUSH K INTRACELLULARLY with INSULIN & DEXTROSE
39
if a patient has PROLONGED COAGULATION, what treatment should we do? how does it work?
can treat PRE-OPERATIVELY with DESMOPRESSIN, which helps INCREASE CIRCULATING VIII-vWF COMPLEX
40
what are we aiming to do by treating with CALCIUM GLUCONATE? (2)
1. treat HYPERKALEMIA
2. STABILIZE CARDIAC MEMBRANES
41
if a patient has ACIDOSIS, how do we treat? (3 options)
1. REESTABLISH PERFUSION to TISSUES
2. give SODIUM BICARBONATE
3. HEMODIALYSIS if it's an option
42
NEPHROTOXIC DRUGS...
give 2 examples?
what OTHER substance should we use cautiously?; especially for patients who are ____ or ____
--> how can we help PREVENT this?
2 examples?
1. NSAIDs
2. AMINOGLYCOSIDE ANTIBIOTICS
USE RADIOGRAPHIC CONTRAST CAUTIOUSLY; especially for patients who are ISCHEMIC or HYPOTENSIVE!
--> put on IV FLUIDS PRIOR to CONTRAST ADMINISTRATION
43
GASTRIC ASPIRATION PROPHYLAXIS is IMPORTANT for ____ ____ PATIENTS
3 drug options?
RENAL DZ
1. METOCLOPRAMIDE
2. MAROPITANT
3. ONDANSETRON
44
METOCLOPRAMIDE..
used for ____ ____ ___ in patients with RENAL DZ undergoing Sx
RISK & how we avoid it?
GASTRIC ASPIRATION PROPHYLAXIS
in AZOTEMIC PATIENTS, may cause TREMORS & ATAXIA at STANDARD DOSES
avoid it by REDUCING DOSE BY 25-50%
45
___ for GASTRIC ASPIRATION PROPHYLAXIS is safe for DOGS & CATS with RENAL DZ
___ for GASTRIC ASPIRATION PROPHYLAXIS is safe for CATS with RENAL DZ
MAROPITANT
ONDANSETRON
46
GASTROPROTECTANTS for RENAL DZ...
both options can ACCUMULATE in the ____, why?
2 options?
can ACCUMULATE in the KIDNEY because RENALLY ELIMINATED
2 options?
1. H2 RECEPTOR ANTAGONISTS (famotidine)
2. PROTON PUMP INHIBITORS (omeprazole)
47
H2-RECEPTOR ANTAGONISTS...
what type of drug is this?
3 examples?
once IRIS STAGE 3 or 4...
type of drug = GASTROPROTECTANT
3 examples?
1. FAMOTIDINE
2. RANITIDINE
3. CIMETIDINE
once IRIS STAGE 3 or 4, CONSIDER DOSE ADJUSTMENT
48
PROTON PUMP INHIBITORS..
what type of drug is this?
3 examples?
proceed with CAUTION in RENAL DZ patients because....
type of drug = GASTROPROTECTANT
3 examples?
1. OMEPRAZOLE
2. ESOMEPRAZOLE
3. PANTPORAZOLE
proceed with CAUTION in RENAL DZ patients because ACUTE INTERSTITIAL NEPHRITIS reported in humans
49
4 options for PRE-ANESTHETIC agents in RENAL DZ patients?
give 2 examples for second, 3 examples for third
1. ACEPROMAZINE
2. BENZODIAZEPINE
--> DIAZEPAM
--> MIDAZOLAM
3. ALPHA-2 AGONISTS
--> DEXMEDETOMIDINE
--> MEDETOMIDINE
--> XYLAZINE
4. OPIOIDS
50
ACEPROMAZINE...
TYPE of drug?
overall used as a ____ ____
what does it mainly cause?
risk for RENAL DZ patients?
HIGHLY ___-BOUND, so if ____ ___ then ____ DOSE
generally in RENAL DZ patients...
TYPE of drug = ALPHA-1 ADRENERGIC RECEPTOR ANTAGONIST
overall used as an PRE-ANESTHETIC AGENT
mainly causes VASODILATION
risk?
can cause HYPOTENSION when MIXED WITH INHALANT ANESTHETICS, causing DECREASED RENAL PERFUSION
HIGHLY PROTEIN-BOUND, so if PROTEIN LOW then REDUCE DOSE
generally in RENAL DZ patients AVOID IT!
51
BENZODIADEPINES...
overall used as an ___ ____
has MINIMAL ___ effects, so can maintain ____ ____, ____ & ____
HIGHLY ____-BOUND
overall used as an PRE-ANESTHETIC AGENT
has MINIMAL CARDIOVASCULAR effects, so can maintain CARDIAC OUTPUT, RENAL BLOOD FLOW & GFR
HIGHLY PROTEIN-BOUND
52
ALPHA-2 AGONISTS...
overall used as an ____ ____
3 examples?
OVERALL can cause PROFOUND ____, resulting in what 2 things?
urinary effect? what patients should we AVOID using this in?
HIGHLY ____-BOUND
how is it eliminated?
PRE-ANESTHETIC AGENT
3 examples?
1. DEXMEDETOMIDINE
2. MEDETOMIDINE
3. XYLAZINE
OVERALL can cause PROFOUND VASOCONSTRICTION, causing...
1. BRADYCARDIA
2. eventually CO and RENAL BLOOD FLOW/GFR
urinary effect = INCREASES URINE OUTPUT, so AVOID IN PATIENTS WITH URINARY OBSTRUCTION
HIGHLY PROTEIN-BOUND
undergoes RENAL ELIMINATION
53
when MEDETOMIDINE given IM, tends to cause ___ in RBF & GFR
when MEDETOMIDINE given IV, tends to cause ____ in RBF & GFR
IM = DECREASE RBF & GFR
IV = INCREASE RBF & GFR
54
OPIOIDS...
OVERALL, used as an ____ ___
give 5 examples?
which one is HIGHLY PROTEIN-OBOUND? which one can cause BRADYCARDIA
all of these drugs have MINIMAL ____ effects
PRE-ANESTHETIC AGENT
5 examples?
1. FENTANYL --> BRADYCARDIA
2. BUTORPHANOL
3. METHADONE --> HIGHLY PROTEIN-BOUND
4. MORPHINE
5. HYDROMORPHONE
all of these drugs have MINIMAL CARDIOVASCULAR effects
55
what drug should we avoid BOLUS DOSING in RENAL PATIENTS?
why?
what TYPE of drug is it?
avoid BOLUS-DOSING MORPHINE in patients with RENAL DZ
why? = because MORPHINE-6-GLUCURONIDE, metabolite, can cause PROLONGED RECOVERY bc RENAL ELMINATION
this is an OPIOID
56
what 3 things during INDUCTION should we do to REDUCE INADEQUATE OXYGEN DELIVERY TO KIDNEY in RENAL PATIENTS?
1. PRE-OXYGENATION via 3-5 MINUTES 100% O2 PRIOR TO INDUCTION to CREATE OXYGEN RESERVOIR in ALVEOLI & minimize effects of HYPOVENTILATION
2. have SUCTION SUPPLIES AVAILABLE available at BEDSIDE prior to INDUCTION especially patients that have HISTORY OF VOMITING/REGURGITATION
3. TITRATION of (give SLOWLY) drugs that will MINIMIZE CARDIOVASCULAR EFFECTS
57
3 possible INDUCTION agents for patients with RENAL DZ?
1. PROPOFOL
2. ALFAXALONE
3. KETAMINE
58
PROPOFOL...
used as an ____ ____
DOES NOT alter WHAT 2 things?
one risk?
HIGHLY ____-BOUND
INDUCTION AGENT
DOES NOT alter...
1. RENAL BLOOD FLOW
2. GFR
RISK = HYPOTENSION if given as IV BOLUS
HIGHLY PROTEIN-BOUND, so may need DOSE REDUCTION if PANHYPOPROTEINEMIA
59
ALFAXALONE...
used as an ___ ____
has MINIMAL ____ effects
undergoes ____ ELIMINATION after ____ METABOLISM, so a SINGLE BOLUS DOSE IS ____ with patients with RENAL DZ
INDUCTION AGENT
has MINIMAL CARDIOVASCULAR effects
RENAL, HEPATIC, ACCEPTABLE
60
KETAMINE...
used as an ___ ___
overall, INCREASES ____ ____ ____ activation, but has a NEGATIVE ____ effect, which can cause...
INDUCTION AGENT
INCREASES SYMPATHETIC NERVOUS SYSTEM activation, but has a NEGATIVE IONOTROPIC EFFECT, which can cause DECREASED RENAL BLOOD FLOW
61
NORKETAMINE...
= what is it?
in DOGS vs. CATS?
= METABOLITE of KETAMINE (induction agent)
DOGS = HYDROXYLATED to INACTIVE METABOLITE, so OK
CATS = NO FURTHER METABOLISM, so AVOID IN CATS WITH RENAL DZ
62
5 parameters for INTRAOPERATIVE monitoring?
1. ECG
2. TEMPERATURE
3. BLOOD PRESSURE
4. PULSE OX
5. END-TIDAL CO2
63
CENTRAL VENOUS PRESSURE is useful to tell you WHAT about the patient?
if you're OVER or UNDERLOADED with VOLUME/guides FLUID REPLACEMENT
64
URINE OUTPUT INTRA-OPERATIVELY should be what?
LOW URINE OUTPUT may be PREDICTIVE of...
URINE OUTPUT should be 0.5 mL/kg/hour
LOW URINE OUTPUT may be PREDICTIVE of POSTOP RENAL INSUFFICIENCY
65
ALL INHALANT ANESTHETICS CAUSE A DECREASE IN WHAT 2 PARAMETERS?
2 parameters decreased?
1. RBF
2. GFR
66
TRUE/FALSE
FREE FLUORIDE IONS can cause NEPHROTOXICITY and are PRODUCED VIA METABOLISM OF VOLATILE ANESTHETICS, so we should OPT FOR SOMETHING ELSE.
FALSE, all is true but NO EVIDENCE OF RENAL TOXICITY with CLINICAL APPLICATION of INHALANT ANESTHETICS
67
SEVOFLURANE produces ____ ____
there is NO EVIDENCE of...
COMPOUND A
NO EVIDENCE of RENAL TOXICITY when used
68
IV FLUIDS during Sx...
should be made up of a BALANCED ___ solution based on patient's ____ STATUS
we should AVOID ____-CONTAINING SOLUTIONS because can PROGRESS RENAL DZ
what should the fluid rate be? (2)
BALANCED CRYSTALLOID solution based on patient's ELECTROLYTE STATUS
we should AVOID STARCH-CONTAINING SOLUTIONS because can PROGRESS RENAL DZ
fluid rate should be...
1. BASED ON PATIENT'S NEED
2. between 2-10 mL/kg/hour
69
POSITIONING/VENTILATION during RENAL Sx?
TARGET END-TIDAL CO2? (range)
POSITIONING = use EXTRA PADDING bc PATIENTS CAN BE FRAIL/PRONE TO BRUISING
VENTILATION = MECHANICAL VENTILATION can be necessary for patients with METABOLIC ACIDOSIS
TARGET END-TIDAL CO2 = 35-45 mmHg
70
REGIONAL & LOCAL ANESTHESIA for RENAL DZ patients...
4 pros?
if a patient has METABOLIC ACIDOSIS, what's the risk?
pros?
1. REDUCE INHALANT REQUIREMENTS
2. IMPROVE CO
3. IMPROVE RBF
4. IMPROVE GFR
if METABOLIC ACIDOSIS = INCREASED RISK for SEIZURES with LOCAL ANESTHETICS
71
if we use a LOCAL ANESTHETIC for EPIDURAL in a HYPOVOLEMIC, RENAL DZ PATIENT, what's the risk?
therefore, WHAT patients are CONTRAINDICATED for this anesthesia?
LOCAL ANESTHETIC for EPIDURAL, can BLOCK SYMPATHETIC OUTPUT in tissues DISTAL TO BLOCK, causing VASODILATION --> REDUCED CO --> REDUCED RBF/GFR
therefore, CONTRAINDICATED in PATIENTS WITH UREMIC COAGULOPATHY
72
RENAL DZ patients may experience INCREASED SENSITIVITY to WHAT medication post-op?
what MONITORING should we consider? (2)
OPIOIDS
consider POST-OP...
1. ECG MONITORING
2. BLOOD WORK (creatinine/BUN, electrolytes, HCT)
