Final_Renal Flashcards
Kidneys are responsible for
- water conservation
- electrolyte homeostasis
- acid-base balance
- several neurohumoral/ hormonal functions
AKI- types
- prerenal (azotemia)
- renal (kidney itself)
- post-renal (outflow obstruction)
AKI- tx
● No specific tx
● Management aims to limit further injury in sepsis:
○ Treat underlying cause
○ MAP>65mmHg
○ Fluid resuscitation (LR)
○ Vasopressor therapy (Norepi in sepsis = safe for kidneys)
○ Activated C-Protein
○ Steroid replacement (for adrenal insufficiency)
○ Dialysis - mainstay for severe AKI
AKI - anesthesia management
- Rx dosing adjustments: decrease dose, increase interval
- same as tx of AKI
- only life saving surgery for pts with AKI
CKD - what is it?
Kidney damage with GFR <60 mL/min/1.73m for 3 mos or more
CKD - progression
● Stage I
○ GFR decreases→ increases in BUN + Creat
○ Non-linear process - i.e. Creatinine can be normal while 50% dec. GFR
● Stage II
○ Hyperkalemia
○ Body compensates - ↑ blood flow to collecting tubules to get rid of K+
● Stage III
○ Homeostasis and regulation of extracellular fluid compartment volume
■ System starts to become overwhelmed
■ Biggest increase in damage over last ~ decade
CKD complications
- uremic syndrome
- renal osteodystrophy
- anemia
- uremic bleeding
- neuro changes
- CV changes (HTN, HL, silent MI, uremic pericarditis)
CKD management
● Aggressive tx of underlying cause
● Pharmacologic therapy (delay dx progression, prevent further complications)
● Preparation for RRT (access, AV fistula–> peritoneal HD, iHD, RRT)
● Manage BP
● Dietary interventions
● Epo for anemia at all stages of CKD
● Lifestyle modifications
CKD - anesthesia management (pre-op, induction)
Preop: LABS (chem), coagulopathies, anemia; HD regimen
Induction:
-Induction drugs?
■ Most safe to use
■ Thiopental=Dose ↓
(d/t ↑ volume of distribution, ↓ protein binding)
- response
HOTN almost immediately after: be prepared=pressors
-Is succinylcholine safe to use?
K+ released from Sux not exaggerated in CKD=safe to use
*Attenuated SNS activity impairs compensatory vasoconstriction ○ Exaggerated (HD) response to: ■ blood volume ■ PPV ■ body position changes
○ ACEs/ARBS → more HOTN intraop esp if haven’t followed guidelines for pre-op use of Rx
CKD - anesthesia management (maintenance)
Maintenance:
- Balanced anesthesia
(VA + muscle relaxants + opioids = equal mix) - What about sevoflurane?
○ Fluoride Toxicity + Compound A accumulation
○ Do providers use Sevo? Yes in real world (higher flows)
● What about volatile agents?
○ Safe - but could use cause precipitous drop in BP d/t decreased SVR
○ Know which VAs drop SVR more than others
● What about TIVA? ✔ Fine
● What about muscle relaxants?
○ Slowed excretion of Roc/Vec
○ Cisatracurium: No change
● What about neostigmine?
○ MOA prolonged
○ Not a problem if reversing
● What about opioids?
○ morphine/meperidine depends on renal clearance
○ Morphine metabolite may accumulate & cause post-op respiratory depression
○ Careful use of longer acting opioids → make sure breathing well post-op
nephrolithiasis
Kidney Stone
Biggest causative factor of nephrolithiasis
Calcium Oxylate
Struvite
Magnesium ammonium phosphate (often formed from infxn process: UTI)
Biggest growth in which kidney failure over 2014-2017?
Stage 3: GFR 30-59
TURP syndrome is due to
IV fluid volume shifts + plasma solute effects caused by absorption of irrigation solution
CKD - anesthesia management (ivf)
-Intraoperative UO is not predictive of post-op renal insufficiency
-When to bolus IVF? What about K in the fluid?
○ Severe renal dysfunction that don’t req HD or pts w/o renal dx undergoing surgical procedure with high incidence of post-op renal failure – these patients may benefit from pre-op hydration with balanced salt solution
Risks - CKD
- avoid bp cuff on AVF arm
- use hand for PIV, access catheter LAST
- prone to infxn, skin breakdown
Caution with which Rx in CKD?
Opioids
Technique used for AV fistula placement
PNB: brachial plexus block
TURP syndrome
complication characterized by symptoms changing from an asymptomatic hyponatremic state to convulsions, coma and death due to absorption of irrigation fluid during TURP
Location of kidney stones
Pelvis
-usually painless
Ureter
-extremely painful, flank pain, N/V, sweaty, pale, hematuria
ureteral obstruction may cause s/s of renal failure
What may occur if close to passing a kidney stone?
Increased hematuria
Treatment: Nephrolithiasis
ESWL
also ID-ing the composition of stone + correcting predisposing factor: hyperparathyroidism, UTI, or gout
ESWL
- Extracorporeal Shock wave Lithotripsy (non-invasive)
- Focused high intensity acoustic impulses directed at stone in renal pelvis
- Basically pulverizes stone → dust → washed out thru urine
BPH Surgical Options
TUIP Trans-urethral incision of the prostate
TURP
(Trans-urethral resection of the prostate)
● Surgical resection of prostate (radical=remove entire gland: indicated for CA; retropubic, peritoneal (lose nerve fxn))
● Electrocautery or sharp excision
● Laser ablation (laser prostatectomy): req goggles
How to alter course of CKD progression?
Biggest: HTN/BG
-ACEI/ARBs + strict glycemic control
ACEI/ARBs
- Decrease systemic HTN + glomerular HTN
- Renoprotective effects (Reductions in proteinuria, Slowing progression of glomerulosclerosis/neuropathies)
Cause of anemia in CKD
Decreased erythropoietin production by kidneys
*also: excess PTH production – replacing bone marrow with fibrous tissue
Tx: Anemia in CKD
exogenous Erythropoietin (Epoetin) or darbopoetin *in ALL stages of CKD
Target Hgb in CKD
10-11.5 mg/dL
*AVOID BLOOD TRANSFUSIONS
Target Hgb in CKD
10-11.5 mg/dL
*AVOID BLOOD TRANSFUSIONS
Why is it important to avoid blood transfusions in CKD?
Result in sensitization of antigens of human leukocyte antigen complex → makes future kidney transplantation less successful
principal factor contributing to TURP syndrome
hypo-osmolality
contributes to neuro + hypovolemic changes
