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Liver Kidney + Transplant Anesthesia > Kidney + Transplant Anesthesia > Flashcards

Kidney + Transplant Anesthesia Flashcards

1
Q

At what spinal level is the center of the kidneys?

A

Retroperitoneal at L2

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2
Q

RBF

A

~1L/min = 20-25% of Cardiac Output

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3
Q

Why would placing ice packs over the kidneys for rapid cooling be so important?

A

Kidneys have high cardiac output = cools more quickly

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4
Q

How does blood enter the glomerulus

A

Afferent arteriole

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5
Q

How does blood from the kidney enter circulation

A

Efferent Arteriole

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6
Q

What part of the kidney hold 85% of the nephron function

A

Cortical = excrete & regulate

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7
Q

Which part of the nephron holds 15% of nephron function

A

Juxtamedullary = concentrate & dilate urine

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8
Q

A mean arterial pressure (MAP) less than _______ causes filtration to cease?

A

MAP <60
-Afferent arteriole vasodilation

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9
Q

How does neural sympathetic stimulation affect RBF?

A

Activation of the SNS decreases RBF

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10
Q

How does neural parasympathetic nervous system stimulation affect the kidneys?

A

No change

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11
Q

Renal hormones (6)

A

-Aldosterone, ADH, Angiotensin, Atrial Natriuretic Factor, Vitamin D, Prostaglandins

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12
Q

Renal regulation of Acid-Base Balance

A

Countercurrent multiplication = concentration & dilution of urine
-Coming from vasa recta or LOH/Collecting duct

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13
Q

COLT PA

A

1.Carbonic Anhydrase inhibitors = PCT
2. Osmotics = descending limb of LOH
3. Loop Diuretics = Ascending LOH
4. Thiazides = Early DCT ???
5. Potassium Sparing = Late DCT & CD
6. Aquaporins = collecting duct ???

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14
Q

GFR

A

quantity/how much filtrate is formed each minute in all nephrons

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15
Q

Juxtaglomerular Complex Function

A

Regulates GFR & Secretes Renin

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16
Q

Ultrafiltration

A

Fluid & soluble material into Bowman’s capsule

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17
Q

Proximal Convoluted Tubule

A

**Reabsorbs Na the most
-Reabsorption of filtrate (Na)
-2/3 salt & water
-100% organic solutes = glucose & AAs

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18
Q

The Descending limb of LOH, _________________ urine

A

Descending limb concentrates urine

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19
Q

The Ascending limb of LOH is___________ to water, ___________ to ions & urea = hypertonic filtrate

A

-Permeable to water
-Impermeable to ions & urea
=Hypertonic filtrate

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20
Q

The DCT is __________ to water, ________ to ions = hypotonic filtrate.

-Opposite of Ascending Limb

A

-Impermeable to water
-Permeable to ions
=Hypotonic filtrate

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21
Q

Atrial Natriuretic Peptide (ANP)

A

-Senses atrial stretch/overload leading to cascade

-Inhibits renin & aldosterone secretion –> antagonizes Na retention –> dilates afferent arterioles & increases GFR –> systemic vasodilation

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22
Q

Prostaglandins do what to the afferent arteriole?

A

-PG vasodilates afferent arteriole in golmerulus
-Maintain hemodynamics

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23
Q

Direct anesthetic alterations of kidney

A

-RVR + RBF, GFR, Tubular function

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24
Q

Indirect anesthetic alterations of kidney

A

*Circulatory, endocrine, or SNS changes
-Decreased CO –> activates SNS = increased RVR, ADH secretion causing vasoconstriction of afferent arterioles

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25
Q

What anesthetic drugs are associated with catecholamine release?

A

Volatiles= all 3

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26
Q

What volatile agent has been shown to break down into Compound A at low flows?

A

SEVO.

Keep flows >2L

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27
Q

Why avoid meperidine in renal patients?

A

Active metabolite can cause seizures & is not removed by dialysis

28
Q

Atropine & robinul in renal patients

A

Decrease dose d/t reduced protein binding

29
Q

Important to check/verify and document when using regional anesthesia

A

Neuropathies, especially in the legs

-Greater risk of getting motor blockade

30
Q

Regarding regional anesthesia, renal patients have an increased risk of developing this severe medication reaction

A

LAST (acidosis)

31
Q

Intralipids dose

A

20% intralipids
*1.5 mL/kg (LBM) over 1 minute. Repeat bolus 1-2x for persistant CV collapse

*0.25mL/kg/min over 20min infusion

-Increase up to 0.5mL/kg/min for refractory HoTN

-Continue infusion for at least 10min after attaining circulatory stability

32
Q

IV drugs & renal patients

A

Variable often d/t increased Vd, decreased protein binding, low pH

33
Q

Sodium Thiopental & renal patient

A

AVOID!
Exaggerated Effect
75-85% bound to albumin

34
Q

Propofol & renal patient

A

Safe for induction/maintenance
-No accumulation

35
Q

Ketamine & renal patient

A

AVOID
-Detrimental increase in BP & CO
***Accumulation

36
Q

Narcotics & renal patient

A

exaggerated effects
-Remi = not dependent on renal function for elimination (plasma esterases)

-Dilaudid = hydromorphone-3-glucuronide accumulates

37
Q

Volatile Anesthetics & renal patient

A

-Do not rely on kidney function for elimination
-Avoid reductions in CO
-SEVO & compound A
-Fluoride nephrotoxicity level of 50 umol

38
Q

Succinylcholine raises serum potassium levels by approximately …..

A

0.5 mEq/L

39
Q

Vecuronium & renal patients

A

Excreted renall & prolonged 30%

40
Q

Rocuronium & renal patients

A

May be prolonged

41
Q

Be mindful of ___________ during renal artery anastomosis etc.

A

Bleeding

42
Q

What is the most common indication for renal transplantation?

A

Type II DM

43
Q

Recipient of renal transplant must have normal coags & ineffective production of ….

A

Ineffective production of Factor 8 + vWF

44
Q

What is harvest organ preservation & ischemic time goal?

A

Less than 30min
-Diuresis begins quickly

45
Q

Donor may have this vasoactive & renal protective medication infusing

A

Dopamine 1-3 mcg/kg/min

46
Q

T/F = renal patients typically have gastroparesis

A

True
-Give lower dose Reglan (H2 antagonist)

47
Q

Fluids for renal patients

A

Conservative management with NS +/- dextrose.

-Consider Plasmalyte

48
Q

You do not want to treat/manage preop HTN because it could effect the kidneys… T/F

A

F
-Treat/manage preop HTN

49
Q

Outside of GETA, what other anesthetic techniques could be used for renal transplant

A

Epidural for postop pain management

50
Q

Induction of anesthesia w/ propofol in renal transplant patient

A

RSI with Higher induction dose of propofol d/t anemic + hyperdynamic state

51
Q

Remifentanil metabolite

A

Can accumulate in ESRD even though metabolized by plasma esterases

52
Q

Volatile agents for renal transplant

A

ISO = skeletal muscle relaxant, minimal metabolism, N2O

53
Q

What does mannitol & furosemide facilitate during renal transplant?

A

Urine output & reduction in tissue & intravascular volume

54
Q

Blood glucose control goals for renal transplant

A

Tight control: 80-110 mg/dL

55
Q

High alert when release of clamp during renal transplant surgery. Why?

A

Cardiac arrest can occur when release of clamp

56
Q

Special attention to _______, ________, ________ , and _________ regiments with immunosuppressants

A

Sterile technique
Antibiotic
Antifungal
Antiviral regiments

57
Q

Tacrolimus used with adrenal corticosteroids increase risk of…..

A

Anaphylaxis

58
Q

Tacrolimus (Prograf) metabolism etc

A

-CYP450
-Causes up regulation
-Nephrotoxic : used with cyclosporine
-1st does w/in 24hr of transplant

59
Q

Adverse effects of mycophenolate (Cellcept)

A

GI, Heme, HTN, HLD, Ischemic vascular disease, tremors, nephrotoxic

60
Q

When can Mycophenolate (Cellcept) be given with renal transplant?

A

Not until renal allograft function has reduced creatinine level to 1/2 of admission value

61
Q

How does mycophenolate affect neuromuscular blockade

A

Enhances neuromuscular blockade produced by atracurium

62
Q

Transplant patient for nontransplant surgery

A

-Abx, antiviral, antifungal & immunosuppressants not messed with
-Renal fxn & choice of neuromuscular blocker important! as well as Abx & other drugs
-Maintain renal perfusion & adequate volume replacement = CVP monitoring
***AVOID NSAIDS

63
Q

Transplant patient presents for surgery w/ signs of acute rejection or infection…. what do you do?

A

May benefit from delay and given time to optimize

64
Q

Lung transplant pt for non-transplant surgery

A

-Tracheal anastomosis, denervation below suture, diminished cough reflex
-Increased airway hyperreactivity & bronchospasm
-Preop PFT, ABG, CXR

65
Q

Heart transplant pt for non-transplant surgery

A

-Denervated heart = no response to indirect agents (ephedrine, dopamine)
-Beta receptor effects exaggerated (EPI & NE) in heart transplants
-Isuprel = chronotropic therapy
-EKG = 2 P-waves
-GETA d/t unable to compensate for hemodynamic changes w/ regional

Liver Kidney + Transplant Anesthesia (2 decks)

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