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NA 1 > GU - Exam 6 > Flashcards

GU - Exam 6 Flashcards

1
Q

Which kidney rests lower, why?

A

right kidney, hepatic displacement

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2
Q

What holds kidneys in place?

A

-large vessels
-renal fascia

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3
Q

Most outer aspects of kidney are convex, which is oncave?

A

medial margin due to the hilus

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4
Q

Inner medulla of kidney has _ - _ pyramids

A

8-18

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5
Q

Renal pyramids have striations, why?

A

loops of henle and collection ducts of nephrons

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6
Q

Three buffering systems in the body:

A

respiratory system
renal system
protein buffers

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7
Q

Where is the nephron located? Where does it begin and end?

A

partly in renal cortex and partly in medulla

begins: cortex at the glomerulus

ends: where tubule joins collection duct at papilla

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8
Q

The glomerulus is a tuft of _ derived from the _ arteriole

A

capillaries
afferent

-blood comes to nephron via afferent arteriole and what isn’t sent into nephron to get filtered gets sent to efferent arteriole back to systemic circ.

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9
Q

Flow of filtrate :
1. Into the _, then into the _ capsule
2. From there, into tortuous path in _ _ tubule
3. Then to the _ of _, then the _ _ tubule, then the _ _.

A

Glomerulus -> Bowman Capsule -> Prox Conv. tubule -> Loop of Henle -> Distal. Conv tubule-> collection duct

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10
Q

Renal cortex contains which structures?

A

-Bowman capsule
-glomerulus
-prox and distal conv. tubules

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11
Q

Which part of loop of Henle comes from proximal tubule towards pyramid, which part joins the distal tubule?

A

proximal tubule -> descending loop ->pyramid

ascending loop -> distal tubule

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12
Q

2 kinds of nephrons and where they go?

A

Cortical nephrons: only partly into the medulla

Juxtamedullary nephrons: sit deep in cortex, extend deep into medulla

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13
Q

_ nephrons comprise 1/5 to 1/3 of total nephrons and concentrate urine

A

Juxtamedullary

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14
Q

Which direction is the blood (relative to the gloremulus) for the afferent and efferent arterioles?

A

Afferent into the gloremulus
efferent out of the gloremulus

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15
Q

Where does oxygenation of the medulla (kidney) occur?

A

ascending loop of henle

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16
Q

Two main functions of the kidney

A
  1. Excrete end products of metabolism
  2. Control concentration of the body fluids
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17
Q

What happens in the medulla of the kidney?

A

urine creation

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18
Q

What happens in the cortex of the kidney?

A

blood flow thru kidney

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19
Q

What is the pathway of renal blood flow?

A

renal artery
segmental a.
interlobar a.
arcuate a.
interlobular
afferent arterioles
glomerular capillaries
efferent arterioles
peritubular capillaries + vasa recta interlobular vein
arcuate v.
interlobar v.
segmental v.
renal vein

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20
Q

Kidneys are highly vascular, receiving _ - _ L of blood /min or _ - _ % of the CO

A

1.1-1.2 L/min flow
20-25% of CO

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21
Q

T/F O2 gets removed in glomerulus

A

false

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22
Q

CO portion that goes thru kidney is called the _ _ and normal value for that is between _ and _ %

A

renal fraction
20-25%

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23
Q

Which receives more blood from renal blood flow, cortex or medulla?

A

cortex

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24
Q

Renal Blood Flow equation:

A

RBF = Renal plasma flow (RPF) / (1-Hct)

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25
Q

What regulated renal blood flow?

A

-intrinsic autoreg (afferent arteriole dilation and myogenic mechanisms control this)
-neural reg

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26
Q

At which MAP ranges is renal blood flow unaffected?

A

50-180mmHg
- if <50, filtration ceases

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27
Q

Renal blood flow and GFR have a _ relationship

A

direct
-one increases or decreases, so does the other
-GFR reduces = dilation of afferent arteriole
-increased blood flow = GFR increases

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28
Q

Which affects renal blood flow more, SNS or PNS?

A

SNS, and it gets overruled easily via autoreg

PNS doesn’t affect renal blood flow at all

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29
Q

Homeostasis is maintained with kidneys via 3 mechanisms

A

-filtration
-reabsorption
-tubular secretion

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30
Q

Filtration fraction is the amount of renal plasma flow that becomes filtrate and is equal to _ / flow of 1 kidney.

A

GFR

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31
Q

Normal GFR, normal flow to one kidney=

A

GFR = 125mL/min
1 kidney = 650mL/min

filtration fraction = 125/650 = ~19% of plasma flow

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32
Q

Glomerulus produces _ -free filtrate, of which, _ % is reabsorbed by the renal tubules and the other percent is eliminated as urine.

A

protein -free
99% is reabsorbed

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33
Q

GFR depends on:

A

-pressure of glomerular capillaries (60mmHg)
-pressure of bowman capsule (18mmmHg)
-colloid osmotic pressure of plasma protein (28mmHg)

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34
Q

Filtration pressure formula:

A

= capillary pressure (60) - Bowman (18) - oncotic pressure (28)

Normal =~10mmHg (I know math ain’t mathin’, just know 10)

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35
Q

What structure regulates GFR?

A

juxtaglomerular complex
-allows fluid in the distal tubule to change the tone of afferent and efferent arterioles and change GFR
-sits in macula densa, affects many arterioles

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36
Q

Increase or Decrease GFR:

A

INCREASE:
-blood flow
-arteriole dilation
-increased resistance in efferent arteriole

DECREASE:
-afferent arteriole constriction
-efferent arteriole dilation

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37
Q

What are the cells of the afferent and efferent arterioles called in the juxtaglomerular apparatus? What do they contain?

A

Juxtaglomerular cells (smooth muscle cells)
-contain renin

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38
Q

Autoreg process in face of decreased GFR:
1. GFR is decreased and there is overabsorption of of Na and Cl so less in _ tubule
2. _ _ senses this fluid change
3. Afferent arterioles _ and jxa release _
4. _ initiates _ system and increases _ (liver->lung)
5. _ causes vasoconstriction and _ is secreted.
6. _ increases reabsorption of Na and H2O, _ volume in body, increasing pressure in _ and GFR to become normal again

A
  1. distal
  2. macula densa
  3. dilate, renin
  4. renin, RAAS, angiotensin II
  5. Angiotensin II, aldosterone
  6. Aldosterone, increasing, glomerulus
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39
Q

Glomerular capillary has many _ charged pores that are _ - _ nm in size. Substances larger than _ nm and that are not _ charged are easily filtered.

A

negatively
70-100nm
>80nm negatively

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40
Q

The glomerulus is highly permeable to almost everything except _ _.

A

plasma proteins
-glomerular filtrate is almost exactly like plasma but without the protein component

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41
Q

What is the primary function of the proximal tubule?

A

Active (1*) Sodium transport

-Water and other solutes follow as a result of cotransport
-Hydrogen and Cl secretion in exchange for Na and H2O reabsorption also happens
-Electrolyte (K, Ca, PO4, uric acid, HCO3, reabsorption also happens)
-other things like glucose, AA, vitamins, and proteins are reabsorbed too

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42
Q

What are the primary functions of the three parts of the loop of henle?

A

Thin (descending) - water
Thin (ascending) - Na/Cl
Thick (ascending) - Na/Cl

-All three help establish and maintain hyperosmotic gradient of the medulla to conserve Na and H2O
-blood flow slows a bit in macula densa, helping maintain gradient

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43
Q

What are the primary functions of the early distal tubule?

A

Absorbs Na, Cl, K
-Not water
-Location of action thiazide diuretics
Location of macula densa
Makes final adjustments on urine pH, osmolality, and ionic composition

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44
Q

Functions of the late distal tubule

A
  1. Reabsorbs sodium (with aldosterone)
  2. Secrete potassium (for sodium)
  3. Secrete hydrogen ions against the concentration gradient-helps regulate acid/base
  4. Reabsorbs water (with ADH)
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45
Q

Collecting duct functions:

A

-water permeability is controlled by ADH to determine urine conc.

-when present, ADH makes it reduce urine volume and sends water to be reabsorbed in the medullary interstitium

-also secretes some H+ so controls acid/base levels to an extent

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46
Q

Any condition that causes amount of O2 transported to tissues to _ stimulates the release of _ from the kidneys to produce RBC and correct _.

A

decrease
erythropoietin
hypoxia

-when both kidneys are destroyed by renal disease -> anemia

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47
Q

Kidneys secrete:

A

-renin
-H+
-K+
-erythropoietin

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48
Q

Aldosterone
-Produced
-Released
-Renal effects

A

Produced: Adrenal cortex

Released: adrenal cortex

Renal effects: distal convoluted tubule (H2O and sodium)

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49
Q

ADH
-Produced
-Released
-Renal effects

A

Produced: hypothalamus

Released: neural hypophysis, posterior pituitary

Renal effects: Promotes reabsorption of H2O, increases tubular permeability in distal tubule

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50
Q

Angiotensin
-Produced
-Released
-Renal effects

A

Produced: Liver (angiotensinogen)

Released by: Kidneys

Renal effect: angiotensin II (vasoconstriction)

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51
Q

ANF
-Produced
-Released
-Renal effects

A

Produced: Cardiac atria

Released by: Cardiac atria

Renal effects: Inhibits Na+, H2O reabsorption in kidney, enhances renal flow and GFR

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52
Q

Which factors have largest impact on aldosterone release?

A

K level in extracellular fluid > RAAS > Na level in extracellular fluid

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53
Q

ADH is inhibited by stretch of _ _

A

atrial baroreceptors

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54
Q

Stimulation of renin release includes:

A

-beta adrenergic stim
-decreased perfusion to afferent arterioles
-decrease Na delivery to distal tubules

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55
Q

ANF antagonizes effects and secretion of:

A

renin
aldosterone
ADH

-works as strong diuretic, produces dose dependent decrease in BP

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56
Q

Calcium metabolism is influenced by 3 things:

A

-vit D
-PTH
-calcitonin

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57
Q

Vit D is obtained in which 2 ways:

A

-diet
-conversion from UV radiation via cholesterol in skin

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58
Q

Vid D is activated in 2 places:

A

-1st in kidneys (cholecalciferol - > 25-hydroycholecalciferol)
-liver (-> 1,25-dihydroxycholecalciferol)

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59
Q

How do prostaglandins like PGE2 and thromboxane A impact renal excretion?

A

PGE2 = vasodilator
thromboxane A = contracts vasc smooth musc

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60
Q

Which substances are secreted via countertransport in the kidney?

A

Hydrogen
Potassium
Urate

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61
Q

Which renal arteriole does angiotensin II constrict

A

Efferent

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62
Q

How are proteins reabsorbed in the kidney?

A

Pinocytosis

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63
Q

ADH release trigger? inhibitor?

A
  1. Osmoreceptors located near hypothalamus stimulates release
  2. Stretch of atrial baroreceptors inhibits ADH
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64
Q

What is the apex of the medullary pyramid called?

A

papilla

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65
Q

What is the magnitude of the decrease of renal function related to in regional anesthesia?

A

Degree of sympathetic blockade and BP depression

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66
Q

What happens at high levels of SAB (renally)?

A

impaired venous return
diminished CO
reduced renal perfusion

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67
Q

Thoracic levels of epidural cause what changes renally?

A

Moderate reduction in RBF and GFR ONLY if epi is used with LA

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68
Q

What relationship does Cr have to GFR?

A

inverse

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69
Q

What does high BUN tell us regarding pathophysiology?

A

uremia

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70
Q

High BUN, normal Cr (extrarenal or renal)?

A

extrarenal cause

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71
Q

High BUN, high Cr (extrarenal or renal)?

A

renal cause

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72
Q

Creatinine clearance levels and kidney function
-mild
-moderate
-dialysis

A
  1. <50
  2. <25
  3. <10
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73
Q

BUN relation to GFR

A

inverse

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74
Q

BUN
-What is it?
-Normal range
-What is it affected by?
-Best indicator of?
-Early/late indicator of renal disease?

A

End product of protein metabolism
10-20 mg/dL
Altered by state of hydration, muscle wasting, GFR
-Best way of dx urea levels in the body
-LATE indicator of renal disease

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75
Q

When does BUN increase (relative to GFR)?

A

GFR reduced by 50%

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76
Q

Creatinine
-What is it?
-Eliminated by?
-What is it used for (measurement)?
-Range

A
  1. Product of creatin metabolism
  2. Glomerular filtration (almost entirely)
  3. Marker of glomerular filtration
  4. 0.7-1.5mg/dL
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77
Q

What is the normal ratio of BUN/Cr?

A

10:1
-Increases with hypovolemia

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78
Q

Creatinine Clearance
-What does it measure?
-How to do it?
-Normal range?

A

Measures ability of the glomeruli to excrete urine
Most reliable assessment tool for renal function
24 hour urine
95-150mL/min

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79
Q

What effect do general anesthetics have on the renal system?

A

RBF, GFR UO and electrolyte secretion decreased

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80
Q

What effects do catecholamines have on the renal system?

A

Decrease renal perfusion and increase renal vascular resistance

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81
Q

Des and sevo effect on renal system

A

Decrease CO and SVR -> decreased perfusion pressure -> increased renal vascular resistance -> decreased RBF

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82
Q

Sevoflurane (specific) effects on kidney

A

Accumulation of fluoride ions, but not nephrotoxic

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83
Q

Opioids and nitrous effects on renal

A

Same as volatile
Decreased CO and SVR –> decreased perfusion pressure –> increased renal vascular resistance -> decreased RBF

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84
Q

Structures that release H+ into tubular fluid:

A

-epithelial cells of prox tubule
-thick part of loop of henle
-distal tubules
-collection ducts

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85
Q

Acid and base balance begins in _ _ by forming _ _ from carbonic anhydrase reacting CO2 with H2O. H2CO3 becomes HCO3 and H+, sending H+ to tubular fluid in exchange for _

A

epithelial cells
carbonic acid H2CO3
Na+

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86
Q

What happens during alkalosis if filtered amount of HCO3 > H+ secreted?

A

-extra HCO3 reacts with H+ and is absorbed as CO2 into ECF. Remaining extra HCO3 is lost with Na+ as urine

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87
Q

What happens during acidosis when H+ > HCO3 in tubules?

A

combines with phosphate buffers or NH3 and is peed out

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88
Q

Phosphate buffer system includes which 2 components?

A

HPO2- (monohydrogen phosphate)
H2PO4 (dihydrogen phosphate)

-both are poorly reabsorbed and concentrate in tubular fluid.

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89
Q

Which component is more concentrated in phosphate buffer system, HPO2- or H2PO4?

A

HPO2-

90
Q

How does phosphate buffer system work?

A

-Extra H+ in ECF enters tubule + links with HPO2- to make H2PO4 which gets peed out.
-Na+ is traded for H+ and links with HCO3- before entering ECF, making sodium bicarb increasing plasma pH.

91
Q

How does NH3- help improve acidosis?

A

-it is secreted into tubules and combines with H+ to make NH4 and gets peed out with Cl - and other anions

92
Q

All renal epithelial cells produce NH33 EXCEPT

A

THIN part of loop of Henle

93
Q

T/F To fix acidosis, the renal system causes one to urinate basic urine.

A

false. Acidic urine in response to acidosis and alkalotic urine with alkalosis

94
Q

T/F Compound A and inorganic fl ions are nephrotoxic

A

true

95
Q

T/F Current anesthetic tools/agents, when used properly, are nephrotoxic

A

false
-only agent known to be nephrotoxic directly is methoxyflurane - not used

96
Q

S/S fluoride nephrotoxicity=

A

-polyuria, hypernatremia, serum hyperosmolality, elevated UN and creatinine, decreased ClCr

97
Q

Compound A formation factors:

A

-high conc agent
-high temp in CO2 absorber
-low FGF
-high states of CO2 production
-absorbents with strong base activators like Na or K hydroxide (soda lime)

98
Q

Which currently used agent has the POTENTIAL to be nephrotoxic?

A

Sevo
-makes inorganic fluoride ions

99
Q

Current FDA guidelines for Sevo use is for a minimum rate of _ L/min FGF at _ MAC hrs should not be exceeded

A

1L/min
2 MAC hrs

100
Q

T/F All urologic cases that are NOT open are done with cystoscope in supine position

A

false
cystoscope + LITHOTOMY position

101
Q

When performing cystoscopy, best anesthetic choice is:

A

short acting spinal
-analgesia
-lack of muscle movement
-real time assessment of mental status

102
Q

When is most stimulating part of cystoscopy?

A

early with insertion of scope, deepen the pt most here or ensure sympathectomy

103
Q

EWSL is used when stones are < _ - _ mm in the _ or _ ureter

A

10-20mm
proximal or midureter

104
Q

Can a kidney stone in the distal ureter (lower 1/3) be removed via ESWL?

A

no, only ureterorenoscopy, regardless of size; AKA cystoscopy with or without stent replacement and stone removal

105
Q

Kidney stones < _ mm are expected to pass on their own without intervention

A

5mm

106
Q

Med mgmt is used for kidney stones between _ - _ mm but may need surgical intervention anyway

A

5-10mm

107
Q

Kidney stones > _ mm are NOT expected to pass on their own and need urologic intervention usualyl

A

10mm

108
Q

T/F ESWL is considered invasive

A

false

109
Q

How do shock waves break up stones in ESWL?

A

-directly via mechanical stress from shock wave
-indirectly via collapse of cavitation bubbles from trailing negative pressure wave

110
Q

Drawback of ESWL?

A

may need retreatments

111
Q

Best way to check a pt for stones?

A

KUB CT

112
Q

Most (~80%) kidney stones are _ -based

A

calcium( calcium oxalate, calcium phosphate, brushite)
-other include uric acid, struvite, cystine

113
Q

What area can ESWL treat?

A

upper 2/3 of ureter

114
Q

How can the ESWL machine injure the patient?

A

Waves hitting air can cause tissue injury
Patients must be still

115
Q

Lasers may not work on stones > _ - _ cm

A

1.5-2cm

116
Q

Different methods of ESWL and how they work:

A

Electrohydraulic (spark-gap)- underwater discharge, spherically expanding wave

Electromagnetic Lithotripter- coil and metal plate in water filled tube

Piezoelectric Lithotripter-spherical dish sends wave out from small ceramic element

117
Q

Why is ECG lead placement important for ESWL?

A

-R wave is used to trigger shocks

-helps prevent arrhythmias (usually SVT or PVCs)
Surgeon may ask to give glyco or atropine to increase HR to deliver more shocks faster

118
Q

Contraindications to ESWL?

A

Absolute:
Urinary obstruction below stone
Infection
Coagulopathy
Pregnant

Relative:
Aortic aneurysm
Orthopedic implant near stone
Renal insufficiency

119
Q

ESWL complications/side effects

A

Hypo/hyperthermia
Cardiac dysrhythmias
Hemorrhagic blisters of skin/petechiae
Renal edema
Renal hematoma
Lung injury
Flank pain
HTN/Hypotension
N/V
Parenchymal injury
Resp difficulty

120
Q

T/F With ESWL, moderate - severe hemorrhage can appear but is self limiting and resolves spontaneously

A

true

121
Q

T/F It is common for pts to have hematuria after ESWL

A

true
-2/2 blood vessel rupture

122
Q

Nephrectomy
-Anesthesia technique
-Position
-Concerns?

A

General anesthesia is advantageous
-rapid onset, control of pt movement

Epidural for post-op pain
A-line if inferior vena cava or renal vein is involved
Jack-knife/lateral position
-Kidney rest on non-dependent kidney
-Decrease venous return

123
Q

If doing regional for ESWL, block needs to be between _ and _

A

T4-T6- short acting spinal with 50mcg sufentanil would work

124
Q

Preop prep for ESWL:

A

-DC AC for 7-10days before
-need negative urine cx to prevent postop UTI/sepsis
-neg HCG for women of childbearing age
-clear liq and/or laxative for best view

125
Q

What would make a ESWL an emergent case?

A

-s/s infection
-obstructed kidney

126
Q

Intra/postop safety for ESWL:

A

-hydration to promote diuresis of lil bits that remain, decrease hematuria
-strict laser protocols (eye protection)

127
Q

Nephrectomy complications

A

Chronic pain can ensue
PE/DVT
Pneumothorax
Brachial plexus injury

128
Q

Are pacemakers an absolute contraindications to ESWL?

A

No
-Pacer may sense ESWL shock as arrhythmias unless designed to handle applied currents
-switch to fixed mode if possible

129
Q

Contraindications to shockwave lithrotripsy

A

Active UTI
Uncorrected bleeding/coagulopathy
Distal obstruction
Pregnancy

130
Q

What alters BUN?

A

Ingestion of protein
Anabolic/catabolic states
GFR
State of hydration
Reabsorption of urea nephron

131
Q

What do the papillary ducts empty into?

A

minor calyx

132
Q

Percutaneous nephrolithotomy
-Anesthesia
-Positioning
-Stone removal methods

A

General ETT
Prone or supine
-Rigid fluoroscopy to remove stone
-Laser, electrohydraulic
-Ultrasound

133
Q

Percutaneous nephrolithotomy complications

A

Major:
-Infection
-Bleeding
-Pelvic/ureteral tears
-Pneumothorax/hemothorax
-Anaphylaxis

Minor:
-UTI
-Renal colic
-Fever
-Pain

134
Q

Percutaneous nephrolithotomy can be used to remove stones _ mm or smaller and requires _ _ and postop _

A

25mm
GA
postop hospitalization

135
Q

Which substances are secreted via countertransport in the kidney?

A

Hydrogen*
Potassium*
Urate

136
Q

Which substances are cotransported in the kidney?

A

Glucose
Amino acids
chloride
phosphate
calcium
Mg
H+ ions*

137
Q

Types of TURP irrigation

A

Cytol
-Sorbitol + mannitol

Glycine
-Amino acid

Physiological saline

138
Q

BPH can be managed with _ _ if the glands are small

A

laser therapy

139
Q

T/F High risk pts with BPH can be managed with TURP

A

false,
transurethral microwave treatment and intraprostatic stents

140
Q

Gold standard for surgically treating BPH:

A

TURP

141
Q

Drugs used in med mgmt of TURP:

A

Alpha Blocking Agents:
-Alfuzosin (Uroxatral)
-Tamulosin (Flomax)
-Doxazosin (Cardura)
-Terazosin (Hytrin)

5-alpha-reductase inhibitors
-Finasteride (Proscar)
-Dutasteride (Avodart)

142
Q

TURP anesthestic technique

A

Spinal (more dense blk than epidural)
-Preferred because you can see s/s of hypervolemia and bladder perforation
-T10 sensory level

General
-Good for patients who cannot tolerate fluid load
-Good for patients who cannot tolerate the sympathetic loss

143
Q

TURP complications

A

Hyponatremia/hypervolemia
Hemorrhage
Bladder perforation
Glycine toxicity
Ammonia toxicity
Infection
Hypothermia
Skin burn

144
Q

What affects the risk of hemorrhage during TURP?

A

Surgeon skill
Duration of surgery (2.5 cc/min loss)
Size of tumor

145
Q

What is glycine toxicity? s/s?

A

Glycine is an inhibitory transmitter
-Many are located in the retina
-TURP blindness can occur from overabsorption of glycine
-Nausea
-Fixed/dilated pupils
-No muscle coordination
-CNS symptoms because glycine breaks down into ammonia

146
Q

What causes the CNS symptoms from glycine?

A

Ammonia excess from glycine breakdown

147
Q

Time frame you can see TURP syndrome emerge?

A

15 mins into case - 24hr after

148
Q

The hallmark clinical symptoms of TURP syndrome are procedure-related due to a combo of:

A

-water intoxication
-fluid overload
-hyponatremia

149
Q

When prostate gland is too large to be remove via TURP what can be done instead?

A

Aquablation
-robot assisted water knife

150
Q

What is TURP syndrome?

A

Intravascular volume shifts, and plasma solute effects caused by absorption of irrigation fluid
-Hypo-osmolality is the main factor

151
Q

1L of irrigant absorption over 1 hour decreases Na+ by how much?

A

5-8mEq/L

152
Q

How much irrigant can be absorbed before CNS symptoms show during TURP?

A

2L

153
Q

At what sodium level do TURP irrigant absorption CNS effects show?

A

<120mEq/L

154
Q

What bag height of the irrigant increases risk for TURP toxicity?

A

60 cm above bladder

155
Q

What increases risk of TURP syndrome? (Surgical time and prostate weight)

A

> 1 hr resection time
80g prostate

156
Q

What kind of breathing with TURP syndrome?

A

Cheyne-Stokes

157
Q

What hematologic issues can occur from TURP syndrome?

A

DIC

158
Q

Patho involved in TURP syndrome:

A

-Fluid Overload
-Water intoxication/ hypoosmolality
-Hyponatremia
-Glycine Toxicity
-Ammonia Toxicity
-Hemolysis
-Coagulopathy

159
Q

Patho of TURP syndrome
-Fluid Overload s/s

A

-HTN
-brady
-arrhythmias
-angina
-pulm edema + hypoxemia
-CHF + HoTN
-hyperglycemia

160
Q

Patho of TURP syndrome
-Water intoxication/ hypo-osmolality s/s

A

-confusion/restless
-twitch/seizures
-lethargy/coma
-dilated and sluggish pupils
-papilledema
-low voltage EEG
-hemolysis

161
Q

Patho of TURP syndrome
-Hyponatremia s/s

A

-CNS changes (lethargy/coma, seizures,etc)
-reduced inotropy
-WIDE QRS
-low voltage EKG
-T wave inversion

162
Q

Patho of TURP syndrome
-Glycine Toxicity s/s

A

-N/V
-HA
-transient blindness
-loss of light/accommodation reflex (blink intact tho)
-DILATED AND FIXED PUPILS
-weakness
-poor musc coordination
-myocardial depression (HoTN, less catecholamines)
-seizures (from NMDA-R stim)
-EKG changes

163
Q

Patho of TURP syndrome
-Ammonia Toxicity s/s

A

-N/V
-CNS depress

164
Q

Patho of TURP syndrome
-hemolysis s/s

A

-anemia
-acute renal failure
-chills/clammy skin
-chest tightness + Bspasm
-hyperK
-bradyarrhythmias/ asystole

165
Q

Patho of TURP syndrome
-Coagulopathy s/s

A

-bleeding
-primary fibrinolysis
-DIC

166
Q

TURP syndrome CV s/s

A

HTN/hypotension
Reflex bradycardia
Pulmonary edema
CV collapse

EKG changes (usually at sodium < 115)
-Wide QRS
-Elevated ST
T wave inversion
-Ventricular arrhythmias (VT/ Vfib) (usually sodium < 110)

167
Q

Amount of fluid absorbed in TURP case depends on:

A

-gland size to be resected
-congestion
-duration of resection
-irrigation solution pressure
-number of sinuses open at a time
-experience of operator

168
Q

An average of _ - _ mL of fluid can be absorbed / minute during TURP so that means in a 2hr case, pt can absorb up to _ - _ L

A

10-30mL/min

6-8L in 2hr

169
Q

Why would distilled water, NS, and LR not be great for irrigating solution for TURP?

A

distilled water is hypoosmolar and RBCs will lyse

LR and NS are ionized and will make high current from rectoscope disperse erratically

170
Q

Hyponatremia usually occurs from _ _, not _ _

A

excess water
sodium loss

171
Q

Progressive increases of MAP, CVP, PAWP suggest _ during TURP procedure

A

hypervolemia

172
Q

_ _ _ may be the first sign of hyponatremia noted.

A

Altered mental status
-this is why regional is better, you can see CNS changes that GA would mask

173
Q

When glucose containing irrigation solutions are used for TURP, transient _ and _ may ensue

A

hyperglycemia and hypoK

174
Q

Bladder perf
-when are s/s seen?

A

-depends on where it is perfed.

-surgeon will see evidence of perf 1st if pt is on GA (inability to recover bladder fluid)

-regional anesthesia is best to notice AMS which may be 1st s/s

175
Q

Bladder perforation treatment

A

Supportive
-stop case
-treat HoTN fluids or pressors
-obtain Hct, start transfusion if needed
-perform cystourethrogram
-maybe suprapubic cath for intraperitoneal fluid or stents to help,
-lap case conversion is worst case

176
Q

Nephrectomy complications

A

Chronic pain can ensue
PE/DVT
Pneumothorax
Brachial plexus injury

177
Q

What is TURP? Indication?

A

-A procedure generally performed in men 60+ years, scope into urethra -> bladder -> resect prostate -> irrigated and distended to wash away prostatic tissue
-Generally done for BPH
-most common adenoma in men

178
Q

Autonomic Dysreflexia
-Spinal level?
-What is it?
-What triggers autonomic dysreflexia?

A

-Generally happens above T5
-Cardiac arrest, dysrhythmias, severe hypertension below cord injury, bradycardia above the level
-Can be prevented with deep enough general, spinal or epidural
-Cutaneous or visceral stimulation
tx: deepen anesthetic, or given antihypertensive

179
Q

5 Q to ask prior to TURP:

A

-What is irrigation fluid
-what is bag height over prostate
-what is size of prostate
-expected duration of case
-position for case (avoid trend)

180
Q

Methods to detect pending TURP syndrome:

A

-serum Na
-monitor for fluid overload
-check mental status
-ethanol breath analysis

181
Q

T/F Treat symptoms and altered labs aggressively when TURP syndrome occurs

A

false
treat labs SLOWLY, if at all

182
Q

Early CNS red flag s/s of TURP syndrome:

A

-N/V
-confusion
-irritability
-HA

183
Q

What are the 2 causes for CNS s/s in glycine toxicity?

A

-Biotransformation into ammonia in liver - > encephalopathy
-NMDA receptor stimulation

184
Q

Ways to avoid skin burns in TURP:

A

-EKG pads
-use of bipolar enucleation of prostate, aquablation, or laser therapy

-monopolar technique has higher risk of burn

185
Q

Blood loss in TURP case is related to 3 things:

A

-weight of resected tissue
-time of case
-skill of surgeon

186
Q

Increased blood loss is seen in TURP cases when there is > _ g of resected tissue and cases > _ min

A

45g
90 min

187
Q

Resected tissue in TURP cases < _ g generally won’t need transfusion while _ - _ g will likely need 2 units of RBC, and > _ g up to 4 units

A

<30g = none
30-80g = 2 units RBC
>80g = 4 units RBC

188
Q

Prevention of TURP syndrome:

A

-avoid trend (promotes absorption)
-limit resection time to <1hr**
-keep prostate capsule intact until end of resection
-put irrigation fluids <60cm above prostate**
-monitor lytes during and after case
-use regional with light sedation to detect mental status changes and DO NOT CONFUSE FOR PT BEING TOO LIGHT

189
Q

Severe TURP syndrome treatment

A
  1. Terminate procedure
  2. Furosemide 20 mg
  3. Send labs for lytes, ABGs, serum osmolality, hct; EKG, art line prolly
  4. Start NS gtt, goal Na > 120 mEq/L
  5. If hyponatremia is symptomatic, tx with 3% NaCl
    -Tx if Na+ under 120, stop when at 120
    -Never more than 100 mL/hr (avoid circulatory overload)
  6. Midazolam (1mg doses) for seizures/twitching, use barb if needed
  7. CXR of pulmonary edema, intubate at earliest s/s pulm edema
  8. Transfuse PRBC (if DIC)
    -Could also give amicar (3-5g 1st hr, then 1g/hr until bleed stopped)
190
Q

Why not correct hypoNa+ quickly?

A

most feared complication = central pontine myelinolysis AKA osmotic demyelination syndrome (ODS)
-osmotic stress ->changes neuronal cells and release myelin toxin
-CNS s/s come in 1 wk and can cause sx, paralysis, or coma

191
Q

How to manage mild TURP syndrome?

A

-maybe nothing needed, just monitor
-supportive tx (antiemetics, atropine, pressors, diuretics)

192
Q

If 3-5% NaCl not available for TURP syndrome tx, ok to use _ % sodium bicarb until 3% or 5% becomes available

A

9% Na Bicarb

193
Q

Best way to check fluid status on TURP pt?

A

TEE

194
Q

Pain impulses from the bladder neck and prostate are propagated by _ _ fibers from the _ and _ sacral roots along with pelvic _ nerves.

A

afferent PNS
2nd and 3rd
splanchnic

195
Q

The sympathetic nerves via the _ plexus, which is derived from _ - _ nerve roots transmit sensation from the bladder, so a _ sensory block is needed for good anesthesia

A

hypogastric
T11-L2
T10

196
Q

Why would GA be good for a pt having a TURP done?

A

if they can’t handle fluid load to compensate loss of sympathetic tone from regional or if they need pulmonary support

197
Q

What can be given to a pt pre-TURP if they are having regional anesthesia to prevent HoTN

A

fluid loading CAUTIOUSLY

198
Q

Urogenital system is a _ system and if insufflated with CO2 will communicate with thorax and subq tissue freely

A

retroperitoneal

199
Q

Intraperitoneal pressure > _ mmHg results in hemodynamic changes like reduced CO and increased SVR

A

10mmHg

200
Q

_ (increased/decreased) renal perfusion activates RAAS system

A

decreased
-causes vasoconstriction

201
Q

Ideal IV fluid to use for TURP case:

A

NS

202
Q

Pros of lap cases:

A

-more precise procedure from magnification of site
-less postop pain
-better cosmetic results
-quicker return to normal activity
-decrease LOS
-cost of care reducion
-less intraop bleeding
-fewer postop pulm and wound infections
-less metabolic changes
-better postop resp function

203
Q

Cons of lap cases:

A

-possible extravasation of insufflated CO2 to retroperitoneal space/ thorax
-possible postop airway compromise from emphysema
-acidosis more frequent from CO2 absorption
-intraop oliguria more frequent from peritoneal pressure increases
-possibly longer case than if open

204
Q

What can be done to improve splanchnic and renal perfusion during lap cases?

A

SCD on BL LE 15 min after pneumoperitoneum achieved

-lowers SVR, improves CO

205
Q

Radical cystectomy
-Approach
-Anesthetic
-Position

A
  1. Remove part or all of bladder (usually for bladder CA, urostomy)
    2.
    -Monitor u/o closely
    -Procedure 4-6 hours
    -EBL 1.5L
206
Q

Radical prostatectomy
-Approach
-Anesthetic
-Position

A
  1. Retropubic/perineal
  2. General/regional/combo
    -Massive blood loss
  3. Steep trendelenburg with lithotomy lap or robot
207
Q

2 main type of major urologic surgeries:

A

Upper Tract Surgery
-simple or radical nephrectomy
-radical nephroureterectomy
-nephron-sparing surgery

Pelvic Surgery
-radical cystectomy
-urinary diversion
-radical prostatectomy

208
Q

Benefits of robot cases:

A

-enhanced and magnified 3D view
-less scattered ambient light
-less surgeon fatigue
-less hand tremor
-better dexterity
-bloodless field
-less blood loss
-shorter LOS

209
Q

Major complications of cases done in trend position:

A

-neuropathy
-CVP elevation
-IOP + ICP elevation
-increased pulm venous pressure
-less pulm compliance
-less FRC
-swelling of face/airway

210
Q

Prolonged lithotomy position problems:

A

-lower extremity nerve issue (usually femoral n
-compartment syndrome and PI on LE

211
Q

Prolonged trend position problems (nerve)

A

ocular injury
-corneal abrasions, ischemic optic neuropathy from high IOP

212
Q

T/F Most organ donation comes from live donors

A

false
brain dead

213
Q

Why would someone need a nephrectomy?

A

tumor or polycystic problems

214
Q

Open nephrectomy is performed in which position? What are some problems with this?

A

jack knife lateral position with rased kidney rest or bump to displace it superficially

-vena cava is compressed! decreased venous return and BP
-decreased compliance, increased PIP, atelectasis possible in dependent lung
-this case is very stimulating so need really good anesthesia on board (maybe lowers BP more)

215
Q

If pt has scleral edema, what else is probably edematous?

A

airway/ vocal cords
wait longer to extubate or don’t

216
Q

Urologic robot cases position:

A

steep trend (~27degrees), arms wrapped at sides

217
Q

Drugs to reduce gastric acid and increase emptying for robot cases :

A

metoclopramide, famotidine

218
Q

What can be given in recovery for bladder spasm?

A

Buscopan
-can increase HR tho

219
Q

Urologic robot cases and fluid:

A

-limit therapry while lower renal tract is disrupted (<800mL)
-give ~1200mL once reconnected and confirm w surgeon
(total 2L)
-blood loss usually <300mL

220
Q

Emergence tips for urologic robot cases:

A

-after robot disengaged, level bed and do lung recruitment maneuvers
-consider spinal (want ~3hr coverage)
-sit pt up and slow wake up ~10-15 min to reduce cerebral edema and agitation-check -for cuff leak before extubating

NA 1 (31 decks)

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