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Anesthesia based on Nebuchanedzzer II > ITE Renal, Urinary, Electrolytes > Flashcards

ITE Renal, Urinary, Electrolytes Flashcards

1
Q

How do you calculate FENA (the kidney’s ability to concentrate urine)?
Prerenal value
Intrinsic value
Postrenal value

A

(Pcr x Una) / (Pna * Ucr)) x 100

Prerenal value: <1%
- volume depletion state (renal tubules absorb Na and water in response)

Intrinsic value: >2%
- decreased ability of renal tubules to conserve sodium

Postrenal value: >4%

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2
Q

BUN varies (directly/indirectly) with GFR, but can also vary independently of GFR.

A

inversely

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3
Q

What is the BUN/Cr of
Prerenal
Intrinsic

A

Prerenal: >20:1
- vol depletion stimulated Na and H2O reabsortion, which also increases urea reabsorption

Intrinsic: <20 (ATN)
- renal damages reduce reabsorption of BUN

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4
Q

What is the Usodium of
Prerenal
Intrinsic

A

Prerenal: <20
- reabsorbed to enhance H2O reab.

Intrinsic: >20
- kidney is damaged and cannot abs as much Na

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5
Q

What are urea and creatinine

A

nitrogenous end products of metabolism

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6
Q

Dermatome level up to ___ is targeted for TURP procedures

A

T10 - sacral nerve roots

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7
Q

Prostate is innervated by ___ nerve roots

A

S2-3

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8
Q

Bladder sensation is supplied by the _____

A

hypogastric plexus, formed from T11-L2

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9
Q

Signs of bladder perforation in an awake pt intraop

A
  1. hypotension
  2. abd pain
  3. Shoulder pain (rupture into peritoneum irriates diaphragm)
  4. hiccups
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10
Q

TURP syndrome with

  • Distilled water
  • Glycine containing soln
A
  • Distilled water: severe hyponatremia and hypoosmolar

- Glycine containing soln: blindness (glycine is transformed into ammonium)

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11
Q

What dermatome lvl for each:

The xiphoid process

The terminal point of the 12th rib

A

T6

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12
Q

Large molecules are unable to pass through semipermeable membrane used for HD and not removed. What products will you see elevated following?

A

Albumin + prealbumin

*urea, Cr, all the electrolytes can cross

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13
Q

Independent risk factors for post op AKI in noncardiac sx

A 
Age >59
BMI >32
Chronic Liver Disease
COPD req chronic bronchodilators
Emergency/High risk sx
PVD
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14
Q

ACEi stop production of ______ and subsequently decrease remodeling of the heart induced by ____ receptor stimulation

A

Angiotensin II

AT1

  • cardiomyocyte hypertrophy
  • proliferation
  • fibrosis
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15
Q

Angiotensin II results in _______ through AT1 receptors

A

Increased

  1. Inotropy
  2. Chronotropy
  3. Catecholamine release
  4. Aldosterone
  5. Vasopressin
  6. Cardiac remodeling
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16
Q

________ slows vasospasm and causes upper extremity vasodilation better than other types of anesthesia for AV fistula creation

A

Brachial plexus blockade

- better than local, GA, MAC

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17
Q

Fentanyl is metabolized through what?

A

CYT P450 3A4

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18
Q

Partially renally excreted medications that may need to be adjusted

A
  1. Anticholinesterase (Neostigmine, edrophonium, pyridostigmine)
  2. Muscle relaxants (Rocuronium, Vecuronium)
  3. Anticholinergics
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19
Q

_____ is a more reliable measure of renal function (and imminent AKI), and does not depend on age or presence of a steady-state.

A

Creatinine clearance
CCr = (Urine Cr * Urine Vol) / Plasma Cr

*2 hour urine collection

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20
Q 
What is the GFR for
Normal kidneys:
Stage one kidney disease:
Stage two
Stage three
Stage four
Stage Five (ESRD)
A 
Stage one (normal): >90 mL/min
Stage two: 60-89 mL/min
Stage three: 30-59 mL/min
Stage four: 15-29 mL/min
Stage Five (ESRD): <15 mL/min
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21
Q

______ is the most common cause of death in pts with ESRD

A

cardiovascular disease

22
Q

Which muscle relaxants do NOT have altered clearance d/t absences of renal clearance?

A
  1. Cisatracurium
  2. Atracurium
  3. Mivacurium

*Vecuronium is completely reliant on renal elimination

23
Q

Morphine and Meperidine use in pts with CKD, and how they can cause severe respiratory depression

A

Both metabolize to potentially neurotoxic compounds that are renally excreted

  • Morphine-3-glucuronide
  • Normeperidine
24
Q

Induction agent Drugs that are completely dependent on renal elimination and require renal dose adjustment in renal failure.

A

Phenobarbital

Thiopental

25
Q

Antimicrobial Drugs that are completely dependent on renal elimination and require renal dose adjustment in renal failure.

A
  1. Vancomycin
  2. Cephalosporins (ie: cefepime)
  3. Aminoglycosides
  4. PCN
  5. Sulfonamides
26
Q

Analgesic Drugs that are completely dependent on renal elimination and require renal dose adjustment in renal failure.

A
  1. Codeine
  2. Meperidine
  3. Morphine
27
Q

Muscle relaxant Drugs that are completely dependent on renal elimination and require renal dose adjustment in renal failure.

A
  1. Pancuronium

2. Vecuronium

28
Q

Cholinesterase Drugs that are completely dependent on renal elimination and require renal dose adjustment in renal failure.

A
  1. Neostigmine

2. Edrophonium

29
Q

Cardiovascular Drugs that are completely dependent on renal elimination and require renal dose adjustment in renal failure.

A
  1. Atropine
  2. Glycopyrrolate
  3. Digoxin
  4. Hydralazine
  5. Milrinone
30
Q

(Hyper/hypo)calcemia associated with ESRD?

A

Hypocalcemia
- Kidney loses ability to reabsorb Ca
- Kidney is responsible for converting 25-hydroxycholecalciferol to 1,25-hydroxycalciferol
(which is responsible for absorbing Ca in the GI tract)

31
Q

Electrolyte abnormalities assoc w/ ESRD

A
  1. Hypocalcemia
  2. Hyperkalemia
  3. Hypermagnesemia
  4. Hyperphosphatemia

*Na is not specific to CKD

32
Q

What happens to Creatinine levels in pts with complete loss of kidney function

A

Doubling of creatinine in first day

33
Q

normal urine osm values

- what happens after fluid restriction?

A

300-900 mOsm/kg

Can be > 800

34
Q

When the body senses hypovolemia or hypotension, the ___ senses it and then there is significantly increased levels of ___ 20 minutes later by the actions of RAAS

A

Juxtaglomerular apparatus (JGA) of the glomeruli

Angiotensin II

35
Q

Describe the RAAS system (6 steps)

A
  1. Renal perfusion and [Na+] are sensed by the macula densa of the proximal tubules
  2. Macula densa cells are part of the JGA
  3. Renin is produced by the JGA
  4. Renin cleaves angiotensinogen to angiotensin I
  5. Angiotensin I is cleaved to Angiotensin II by ACE (in the lungs)
  6. Angiotensin II increases blood pressure by DIRECTLY causing arteriolar vasoconstriction throughout the body, ensuring adequate glomerular filtration
  7. Angiotensin II INDIRECTLY increases BP by stimulating the secretion of aldosterone from the zona glomerulosa of the adrenal glands
36
Q

Why do pts taking ACEi or ARBS the day of surgery present a hemodynamic problem?

A

Chronic blockade of the RAAS inhibits angiotensin response to acute hypotension as well as the vasoconstrictor response to norepinephrine
–> more pronounced and refractory hypotension, esp after induction

37
Q

Cardiac surgery have an AKI risk of __%, especially if CPB is used.

A

30%

38
Q

Transplant surgery have an AKI risk of __%

A

70%

39
Q

What type of lithotripsy (breaking of renal calculi) is contraindicated in pregnant patients?

A

Extracorporeal shock wave lithotripsy (ESWL)

*Laser lithotripsy ok

40
Q

Recommended dermatomal spread of neuraxial anesthesia in lithotripsy procedures (think about renal innervation)

A

T6

- Renal innervation is derived from T10-L2

41
Q

(Perioneal/traditional hemodialysis) mode of dialysis is preferred in pts who cannot tolerate hemodynamic changes (ie. unstable angina, severe AS, poor HF)

A

Peritoneal dialysis
- placement of the catheter into peritoneal cavity -> dialysate is infused into abd and peritoneal membrane will allow solute transport out of blood stream

42
Q

Most pts needing emergent dialysis would be initiated on (Perioneal/traditional hemodialysis) mode of hemodialysis

A

traditional hemodialysis

43
Q

ECG signs of hypokalemia

A

ST segment and T wave depression, u wave elevation

  • Afib
  • Premature ventricular beats
44
Q

Serum K of < ___ warrants delay of nonemergent sx

A

< 2.5 meq/L

*if 2.5-3.0, check EKG

45
Q

The organ most sensitive and least sensitive to ischemia time is the ____.

A

Heart (4h)

Kidney (24h)

46
Q

What is the purpose of low serum bicarb in a pt with high anion gap metabolic acidosis?

A

Serum bicarb was used to buffer the excess acid (H+) in pts with met acidosis then serum levels fall without an equal increase in Cl-

47
Q

How to calculate Anion gap?

Normal range?

A

Anion gap = Na - (Cl + HCO3)

Normal 8 - 16 meq/L

48
Q

What type of acidosis if found with excessive administration of 0.9% NS?

A

Hyperchloremic metabolic acidosis

- NS has 154 meq of Cl compared to 98 in plasmalyte

49
Q

(Hyper/hypo)phosphatemia associated with ESRD? WHy?

A

Kidneys lose ability to secrete calcitriol (stim bone growth) ->
PTH increases ->
Increses bony turnover and mobilizes phosphorous from the bones themselves ->
Kidneys lose ability to excrete phosphorous ->
Hyperphosphatemia

50
Q

(Hyper/hypo)albuminemia associated with ESRD? Why?

A

Decreased synthesis and increase catabolism of albumin

51
Q

(Hyper/hypo)kalemia associated with ESRD? Why?

A

Decreased excretion

52
Q

Electrolyte changes with loop diuretics

  • Calcium
  • Magnesium
  • Sodium
  • Uric acid
A
  • Calcium: decrease
    “Loops lose calcium”
  • Magnesium: decrease
  • Sodium: decrease
  • Uric acid: increase

Anesthesia based on Nebuchanedzzer II (38 decks)

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