Principles-Renal/GU disease and procedure management

Question 1

Renal pain sensation is conveyed to which spinal cord segments

Answer 1

T10-L1

Question 2

Sympathetic innervation is supplied by preganglionic fibers from

Answer 2

T8-L1

Question 3

The vagus nerve provides PS invervation to the kidney, but what PS fibers supply the ureters

Answer 3

S2-S4

Question 4

The bladder receives its innervation from sympathetic nerves originating

Answer 4

T11-L2

Question 5

PS fibers transmit bladder stretch sensations and motor function to

Answer 5

S2-S4

Question 6

Describe the Renin-Angiotension-Aldosterone System’s responds to hypovolemia, hypotension, and hyponatremia

Answer 6

Liver hepatocytes constantly produce angiotensinogen which circulates in the plasma

Juxtamedullary apparatus is composed of afferent arteriales and macula densa cells in distal convoluted tubules. Macula densa (chemoreceptors) sense decreased sodium and relase renin.

Renin convertes angiotensinogen to angiotension I. Angiotensin I is converted to Angiostensin II by ACE found in lungs.

Angiotensin II stimulates hypothalmus’ thirst center and signals it to cause posterior pituitary to release ADH.

ADH increase aquaporin presence in collecting tubule to reabsorb water

Angiotensin II stimulate the adrenal cortex to release Aldosterone

Aldosterone increases NaCL channels in ascending loop of henle, and collecting ducts while causing potassium to be excreted

Angiotension II is a potent vasoconstrictor which increase blood pressure

Net result is a increase in plasma volume and bp

Question 7

What mechanisms antagonize the RAAS

Answer 7

Atrial Natriuretic peptide

• blocks reabsorption of sodium in DT and CD
• increases GFR
• inhibits the release of renin

Nitric Oxide
-opposes renal vasoconstrictor effects of angiotensin II and SNS

Renal prostaglandin system
-during times of stress, opposes ADH and RAAS

Question 8

Assessing kidney fx is best done by observing the

Answer 8

filtration rate

Question 9

Acute declines in the filtration capacity indicate

Answer 9

kidney injury and predict a more complicated clinical course

Question 10

What is the normal GFR

Answer 10

90-140 mL/min

• GFR < 60= impaired
• GFR< 15= uremia and dialysis need

Question 11

What is the most useful clinical marker to assess renal filtration

Answer 11

creatinine

Question 12

what is the normal serum creatinine level

Answer 12

0. 8-1.3 mg/dL men

0. 6-1.0 mg/dL women

Question 13

Can renal dysfunction exist with normal creatinine levels

Answer 13

Yes, because serum creatinine does not usually rise until GFR fall bellow 50 mL/min

Question 14

Should you expect an increase in creatinine as you age

Answer 14

No, because although GFR declines with age, so does muscle mass

Question 15

Following acute kidney injury, should you expect an immediate increase in creatinine

Answer 15

No, In the early stages of severe acute renal failure, the serum creatinine may be low even though the actual GFR is markedly reduced

Question 16

Anesthetist use urinalyisis to assess

Answer 16

urine drug screen
urine pregnancy test
protein analysis

Question 17

Is it possible to have renal failure without oliguria

Answer 17

Yes- the majority of perioperative renal failure demonstrate this

Question 18

During times of stress (trauma and shock), how does the SNS influence the kidney to restore intravascular volume and maintain blood pressure

Answer 18

release of NE which constricts renal arterioles
activates RAAS»aldosterone & ADH

*Net result is a blood flow shit from renal cortex to renal medulla, sodium and water reabsorption, and decreased UO

Question 19

What will result if the stress response is not reversed

Answer 19

ischemic damage and acute renal failure

Question 20

What is the most common cause of AKI

Answer 20

Acute tubular necrosis

Question 21

List the three primary nephrotoxic agents discussed

Answer 21

NSAIDS

Myoglobin/Hemoglobin

Inhalation Anesthetics

Question 22

NSAIDS are harmful to the kidneys in a distinct population of individuals, namely

Answer 22

advanged age
hypovolemia
the very sick
overdose
renal hypoperfusion or vasoconstriction

*NSAIDS (ketorolac) prevent prostaglandins formation

Question 23

Myoglobin is harmful to the kidneys because it

Answer 23

readily filters at the glomerulus and reabsorbs by the renal tubule, where it chelates NO and induces medullary vasoconstriction and ischemia

Question 24

The effects of anesthesia on the kidneys are usually r/t

Answer 24

CV depressant (bp) effects of anesthesia 
*less marked during regional anesthesia

SNS activation assoc. with light anesthesia, surgical stimulation causes autoregulatory mechanisms of kidney to vasoconstrict which would decrease RBF

Endocrine responses via stress response which causes catecholamine surge and decreased RBF

Question 25

The negative effects of anesthesia on the kidneys can be blunted by maintaining

Answer 25

adequate intravascular volume and a normal blood pressure

Question 26

Name two inhalation agents that can theoretically cause renal toxicity in high doses

Answer 26

methoxyflurane and sevoflurane

Question 27

Of the induction and sedation agents, which drugs will least likely cause an increase in free circulating drug in kidney disease patients

Answer 27

propofol ketamine etomidate *Not highly protein bound

Question 28

The opioid meperidine can increase risk for what in renal disease

Answer 28

seizure r/t active metabolite normeperidine

Question 29

What two opioids are best for patients with renal failure

Answer 29

Fentanyl Remifentanil-metabolized rapidly by ester hydrolysis in blood

Question 30

What type of drug is more likely than any drug used in anesthesia to cause prolonged effects in ESRD patients

Answer 30

muscle relaxants

Question 31

What NDMB will not accumulate in patients with renal failure

Answer 31

Cisatricurium - undergoes Hoffman elimination - increase pH and Temp causes increase in metabolism

Question 32

Patients with ESRD typically cannot excrete potassium resulting in hyperkalemia. Is succinylcholine safe for patient's with ESRD

Answer 32

Yes, if potassium is < 5.5 mEq/L

Question 33

What are the two highest risk surgical patients for renal complicatons

Answer 33

by-pass cardiac patients STAT surgical/trauma patients

Question 34

How do you best prevent AKI in STAT surgeries

Answer 34

management of intravascular volume and shock - restore euvolemia - maintain CO and renal blood flow - maintain 02 delivery - maintain UO > 0.5 mL/kg/hr - avoid NSAIDS, myoglobin leak, contrast media - IV hemodynamic monitoring

Question 35

Is it ok to give furosemide or mannitol in the early resuscitative phase of trauma management

Answer 35

NO -decreases intravascular volume *except in the case of head injury with elevated intracranial pressure or massive rhabdomyolysis

Question 36

Dialysis of renal failure patients should be done how long before surgery

Answer 36

preferablly the day before

Question 37

Which induction agent has minimal effects on CO

Answer 37

Isoflurane

Question 38

What is the most common nerve injury associated with lithotomy position

Answer 38

brachial plexus

Question 39

Excessive flexion at the thigh can cause damage to which nerves

Answer 39

F.O.S | femoral, obturator, sciatic nerves

Question 40

What nerve can be injured laterally b/c of the thigh rest

Answer 40

common peroneal nerve-foot drop

Question 41

What nerve can be injured medially b/c of the thigh rest

Answer 41

saphenous nerve-medial calf numbness

Question 42

Regional techniques for patient's undergoing major cysto procedures require sensory level blockade of what level

Answer 42

T10

Question 43

Name three absolute contraindications for ESWL

Answer 43

bleeding disorders anticoagulation therapy pregnancy

Question 44

What is the gold standard for treating BPH

Answer 44

TURP

Question 45

What is TURP syndrome

Answer 45

a term used to describe the symptoms that occur with excess absorption of irrigating solutions, r/t water intoxication

Question 46

Symptoms of TURP syndrome include

Answer 46

respiratory distress (rapid fluid expansion) HTN Altered mental status hypoosmolarity of plasma symptoms specific to the type of fluid used early symptoms- HTN, bradycardia later symptoms-left HF, pulmonary edema

Question 47

What factors predict TURP syndrome

Answer 47

Number and size of open venous sinuses (bleeding) duration of resection hydrostatic pressure of irrigating fluid venous pressue at the irrigant-blood interface

Question 48

What are the advantages of a regional approach over a general technique for TURP

Answer 48

allows patient to remain awake to dx TURP syndrome and bladder perforation decreased blood loss decreased need for analgesics

Question 49

Patients undergoing radical retropubic prostatectomy are likely to be positioned in

Answer 49

hyperextended supine position with trendelenberg