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1. adv principles 3 exam 1 > renal > Flashcards

renal Flashcards

0
Q

(1)

what are the 3 types of acute renal failure:

A

(1)
what are the 3 types of acute renal failure:
1. pre renal: usually volume depletion
2. infra renal: usually d/t cytotoxic or nephrotoxic drugs, ischemia, inflammatory responses with structural or functional damage
3. post renal: obstruction of urinary tract

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1
Q

objectives:

A
  1. Discuss the causes of acute renal failure.
  2. Recognize the unique physiologic and anesthetic implications of renal disease.
  3. Identify the anesthetics and anesthetic techniques which should be employed for the renal patient.
  4. List the treatment for hypo- and hyperkalemia and other electrolyte imbalances.
  5. Recognize the implications and risks of TURP and TURB procedures, Percutaneous nephrolithotomy, lithotripsy, and other related urologic procedures.
  6. Identify the symptomatology and treatment of TURP syndrome.
  7. Discuss the unique anesthetic modifications for robotic urologic procedures.
  8. Describe the effects of chronic renal failure on various organ systems.
  9. State the physiology of renal blood flow, GFR, acid-base balance, and overall renal function.
  10. Recognize the structure and function of all portions of the loop of Henle.
  11. Verbalize the function of Aldosterone, Renin, ADH, Vit D, Errythropoetin, Angiotensin and describe what controls their release.
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2
Q

(2)

what are some of the causes of ARF?

A 
(2)
what are some of the causes of ARF?
1. dehydration
2. sepsis
3. hemorrhage
4. heart failure
5. liver failure
6. burns
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3
Q

(3)

what are risk factors for ARF?

A 
(3)
what are risk factors for ARF?
1. pre-existing renal insuffeciency
2. CHF
3. diabetic nephropathy
4. hypertensive nephropathy
5. liver failure
6. pregnancy induced hypertension (PIH)
7. sepsis
8. shock
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4
Q

(4)
anesthesia for renal patients:
1. why do highly protein bound drugs have a stronger effect?
2. why will any anesthesia drug have a stronger effect?
3. Drugs will have a longer half life if they are ___? what are examples?

A

(4)
anesthesia for renal patients:
1. why do highly protein bound drugs have a stronger effect?
– renal patient suffer from hypoalbuminemia which leads to a higher free fraction of the drug (the free fraction is what does the action)
2. why will any anesthesia drug have a stronger effect?
– the blood brain barrier is porus and therefore drugs cross causing pronounced effects
3. Drugs will have a longer half life if they are ___? what are examples?
–renal excreted drugs will have a longer half life
—NDMRs etc.

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5
Q

(5)

  1. what is the #1 cause of chronic renal failure?
  2. what is the #2 cause?
A

(5)

  1. # 1 cause of CRF is diabetes
  2. # 2 cause of CRF is HTN
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6
Q

(6)
what is the best anesthesia method for renal patients:
1. for AV fistula?
2. for general surgery?

A

(6)
what is the best anesthesia method for renal patients:
1. for AV fistula?
–local with small doses of fentanyl and versed
2. for general surgery?
– etomidate or ketamine for induction (d/t renal patients are intravascularly dry), sux (if potassium normal) or roc with rapid sequence (d/t usually having gastroparesis from the diabetes), lowest gas (d//t vasodilatory effects)

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7
Q

(7)

  1. At what % loss of neprons do symptoms of CRF occur?
  2. at what % loss of nephrons does dialysis start?
  3. what GFR signifies ESRD (end stage renal disease)?
  4. what is a normal GFR?
A

(7)
1. At what % loss of neprons do symptoms of CRF occur?

  1. what GFR signifies ESRD (end stage renal disease)?
  2. what is a normal GFR?
  3. 80% nephron loss
  4. at what % loss of nephrons does dialysis start?
    - - 90% nephron loss
  5. <15 ml/min
  6. 125 ml/min
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8
Q 
(8)
the 5 stages of renal failure: 
--what is the GFR that signifies each stage?
1. stage 1:
2. stage 2:
3. stage 3:
4. stage 4:
5. stage 5:
A

(8)
the 5 stages of renal failure:
–what is the GFR that signifies each stage?
1. stage 1: kidney damage with normal or slightly decreased GFR (>90 ml/min/1.73 m2)
2. stage 2: mild reduction in GFR (60-89 ml/min/1.73 m2)
3. stage 3: moderate reduction in GFR (30-59 ml/min 1.73 m2)
4. stage 4: severe reduction in GFR (15-29 ml/mon/1.73 m2)
5. stage 5: kidney failure (GFR <15 ml/min/1.73 m2)

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9
Q

(9)

  1. what is the cardiac output that goes to the kidney?
  2. what happens to kidney perfusion when body is in state of shock?
A

(9)

  1. what is the cardiac output that goes to the kidney?
    - - 20% of CO goes to kidneys
  2. what happens to kidney perfusion when body is in state of shock?
    - - the kidneys shunt blood supply to brain and heart
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10
Q

(10)

  1. treatment of hyperkalemia in renal patients:
  2. treatment of hypokalemia in renal patients:
A

(10)

  1. treatment of hyperkalemia in renal patients:
    - - bicarb- shifts K+ back into cell (for every decrease in pH of .1, K+ increases 0.6 because H+ displaces K+)
    - - hyperventilate- decreases CO2 which decreases H+ allowing K+ to re-enter the cell
    - - insulin/glucose
    - - calcium- stabilizes the cell membranes of heart by increasing threshold (makes it harder to reach action potential)
  2. treatment of hypokalemia in renal patients:
    - -Hypokalemia- replace losses prior to surgery
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11
Q

(11)

what are other electrolyte imbalances that may be seen (besides hyperkalemia (or hypokalemia))?

A 
(11)
what are other electrolyte imbalances that may be seen (besides hyperkalemia (or hypokalemia))?
hypercalcemia
hypophosphatemia
hyperphosphatemia
hypermagnesemia
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12
Q

(12)

s/s hyperkalemia:

A 
(12)
s/s hyperkalemia:
peaked T waves
prolonged PR interval
wide QRS
heart block
PVCs
V-fib
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13
Q

(13)

  1. how does a renal patient develop HYPERrmagnesemia?
  2. s/s of HYPERmagnesemia?
A

(13)

  1. how does a renal patient develop HYPERrmagnesemia?
    - - inabillity of nephrons to excrete Mg+ and also from ingesting high quantity of Mg+ containing antacids (d/t indigestion from decreased motility related to underlying diabetes)
  2. s/s of HYPERmagnesemia?
    - - hypotension, hypoventilation, coma (causes muscle relaxation/decreased deep tendon reflexes)
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14
Q

(14)

what (2) issues in renal patients leads to hyperkalemia?

A

(14)
what (2) issues in renal patients leads to hyperkalemia?
1. distal nephrons lose ability to secrete K+
2. acidosis causes K+ to be kicked out of cell (K+ is intracellular but is displaced by H+ during acidosis)

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15
Q

(15)

renal function appears to be normal until GFR is how low?

A

(15)
renal function appears to be normal until GFR is how low?
10-15%

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16
Q

(15)

what is a normal BUN? creatnine?

A

(15)
what is a normal BUN? creatnine?
normal BUN: 10-20 mg/mL
normal creat: 0.7-1.5 mg/dL

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17
Q

(16)

what are s/s of hyperhposphatemia (to what major organs)?

A 
(16)
what are s/s of hyperhposphatemia (to what major organs)?
NEURO:
1. altered mental status
2. delirium
3. obtundation
4. coma
5. convulsions
6. cramping
7. tetanh
8. neruomuscular hyperexcitability
9. paresthesia

CV:

  1. hypotension
  2. heart failure
  3. prolonged QT

EYES:
– cataracts

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18
Q

(17)

  1. what causes hypercalcemia in a renal patient?
  2. what does the “culprit” have to do with calcium?
  3. why does this make positioning a problem?
A

(17)

  1. what causes hypercalcemia in a renal patient?
    - - the inability of the body to convert vitamin D to its active form
  2. what does the “culprit” have to do with calcium?
    - - vitamin D helps the body to absorb calcium
  3. why does this make positioning a problem?
    - -renal patients may have brittle bones d/t calcium absorption issues
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19
Q

(18)
Implications of a turp:
1. what is in the irrigation?
2. what are complications of TURP?

A

(18)
Implications of a turp:
1. what is in the irrigation?
–irrigation consists of mannitol and sorbitol in 100 ml of water or glycine
2. what are complications of TURP?
–reactions consist of bleeding, bladder preforation and turp syndrome

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20
Q

(19)

  1. what are s/s of bladder perforation (in an awake patient)?
  2. what are the big issues with bleeding from a turp?
  3. what should you have prior to turp surgery?
A

(19)

  1. what are s/s of bladder perforation (in an awake patient)?
    - - acute shoulder pain, restlessness, shortness of breath
  2. what are the big issues with bleeding from a turp?
    - - blood loss is hard to track d/t dilution from irrigation
  3. what should you have prior to turp surgery?
    - -have a type and screen available
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21
Q

(20)

what the hell is a turb?

A

(20)

what the hell is a turb?

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22
Q

(21)

  1. how do percutaneous nephrolithotomy and lithotripsy differ?
  2. What are the impliations for percutaneous nephrolithotomy?
  3. What are the implications for lithotripsy?
A

(21)

  1. how do percutaneous nephrolithotomy and lithotripsy differ?
    - -percutaneous nephro-lithotripsy is a scope placed into the kidneys (at the calyx) under fluroscopy. Stones are then pulverized internally. With lithotripsy (ESWL), the stones are pulverized externally
  2. What are the impliations for percutaneous nephrolithotomy?
    - -needs general anesthesia and is either lateral or prone intubated
  3. What are the implications for lithotripsy?
    - - needs moderate to deep sedation or regional anesthesia with T4-T6 or GA
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23
Q

(22)

8 complications of percutaneous nephro lithotripsy:

A

(22)
8 complications of percutaneous nephro lithotripsy:
1. bleeding
2. extravisation of irrigation fluids into tissues
3. inadvertemt perforation of the collecting duct
4. infection/sepsis
5. injury to adjacent organs
6. PTX (high risk of lung damage)
7. hydrothorax
8. hemothorax

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24
Q

(23)

what is a turp

A

(23)
what is a turp?
–a scope is placed in the urethra to shave the median and lateral lobes of the prostate; bladder is distended with continuous irrigation for better view.

25
Q

(24)
robotic surgery (i.e. prostatectomy):
1. what are issues (in general)?
2. what are issues with renal patients?

A 
(24)
robotic surgery (i.e. prostatectomy): 
1. what are issues (in general)?
-a. steep trendelenberg-
-b. GETA with muscle relaxant
-c. pneumoperitonium
-d. protect eyes
-f. OGT
-g. minimal fluids
-h. both arms tucked
2. what are issues with renal patients?
26
Q

(25)

what are issues with steep trendelenberg?

A

(25)
what are issues with steep trendelenberg?
-can cause facial and airway edema
-increased C.O. (intially) then decreases 10-30%
-generalized vasodilation
-decreased stroke volume
-decreased organ perfusion
-increased myocardial o2 consumption
-increased peak inspiratory pressures (PIP) causing difficulty ventilating

27
Q

(26)

what are the 10 biggest issues with deep trendelenberg and pneumoperitonium?

A

(26)
what are the 10 biggest issues with deep trendelenberg and pneumoperitonium?
1. initially increased SVR (which then decreases)
2. increased MAP
3. increased SV (stroke volume)
4. increased CVP
5. decreased gastric pH and mesenteric blood flow
6. decreased renal and liver blood flow
7. compacting of lung bases with limited expandability]
8. poss mainstem intubation
9. venous congestion and swelling of face and airway
10. risk of CO2 embolism

28
Q

(27)
turp syndrome:
-symptoms:

A 
(27)
turp syndrome:
-symptoms:
turp syndrome:
-symptoms: 
a) hyperglycinemia
b) hyperammonemia
c) hypernatremia
d) hypo-osmality
e) hemolysis/anemia
f) acute renal failure
g) death
29
Q

(28)
turp syndrome:
- treatment:

A 
(28)
turp syndrome:
- treatment:
1. fluid restriction
2. loop diuretics
3. hytertonic saline (at rate no higher than 100 ml/hr)
4. versed or dilantin for seizures
5. intubation for airway protection
30
Q

(29)

why cant you run hypertonic saline at higher rate than 100 ml/hr?

A 
(29)
why cant you run hypertonic saline at higher rate than 100 ml/hr?
1. pontine demylenation
2. crenation of RBCs
3. brain edema
31
Q

(30)
what are the effects of chronic renal failure on various organ systems:
-cardiac:

A 
(30)
what are the effects of chronic renal failure on various organ systems:
-cardiac:
1. hypertension
2. ischemic heart disease
3. CAD
4. cardiac failure
5. pericarditis
32
Q

(31)
what are the effects of chronic renal failure on various organ systems:
respiratory:

A 
(31)
what are the effects of chronic renal failure on various organ systems:
respiratory:
1. pulmonary edema
2. pleural effusion
3. respiratory infection
33
Q

(32)
what are the effects of chronic renal failure on various organ systems:
GI

A 
(32)
what are the effects of chronic renal failure on various organ systems:
GI:
1. stress ulcer
2. delayed gastric emptying
3. malnutrition
4. increased risk of GI bleed
34
Q

(33)
what are the effects of chronic renal failure on various organ systems:
Endocrine:

A

(33)
what are the effects of chronic renal failure on various organ systems:
Endocrine:
1. hyperparathyroidism (d/t decreased calcium)
2. adrenal insuffeceincy d/t steroids (half life of steroids prolonged in CRF)

35
Q

(34)
what are the effects of chronic renal failure on various organ systems:
CNS

A 
(34)
what are the effects of chronic renal failure on various organ systems:
CNS:
1. peripheral neuropathy
2. autonomic neuropathy
3. decreased mental acuity
4. convulsions
5. coma (eventually death)
36
Q

(35)
what are the effects of chronic renal failure on various organ systems:
Renal/fluid/electrolyte:

A

(35)
what are the effects of chronic renal failure on various organrenal/fluid/electrolyte
1. renal: altered drug excretion
2. fluid: intravascular dehydration
3. electrolyte: electrolyte imbalance (hyperkalemia, hypocalcemia, hypermagnesemia, hyperhosphatemia)

37
Q

(36)
what are the effects of chronic renal failure on various organ systems:
Immunological

A

(36)
what are the effects of chronic renal failure on various organ systems:
Immunological:
1. immunosuppression (physiological and pharmacological)
2. infection is LEADING CAUSE OF DEATH

38
Q

(37)
what are the effects of chronic renal failure on various organ systems:
hematological:

A

(37)
what are the effects of chronic renal failure on various organ systems:
hematological:
1. anemia (d/t decreased erythropoetin= 20-30% decrease in RBCs)
2. decreased platelet function causing bleeding disposition

39
Q

(38)

how do you treat renal bleeding disorders?

A

(38)
how do you treat renal bleeding disorders?
DDAVP and cryoprecipitate

40
Q

(39)
physiology of renal blood flow:
1. what is the autoregulation pressure for the kidneys to function properly?
2. what happens if person goes into shock?
3. what is “glumeral tubular balance”?

A

(39)
physiology of renal blood flow:
1. what is the autoregulation pressure for the kidneys to function properly?
– blood entering glumerulus is autoregulated at pressures of 50-150mmHg so that it performs normally
2. what happens if person goes into shock?
–blood is shunted away from kidneys to vital organs and the kidneys start to shut down
3. what is “glumeral tubular balance”?
– when there is a decrease in GFR resulting in a decrease in the fluid flow rate within the tubule.

41
Q

(40)

how is GFR hormonally regulated (3 ways)?

A

(40)
how is GFR hormonally regulated (3 ways)?
–hormonally via: vasoconstrictors, vasodilators and by increasing permeability
I. VASOCONSTRICTORS:
-1. angiotensin II: (via renin/angiotensinogen pathway)renin is released by JGA. angiotensin II is a potent vasoconstrictor (of the afferent blood supply) and thus decreases GFR
-2. Endothelin: potent renal vasoconstrictor
II. VASODILATORS:
-1. Nitric Oxide: vasodilator
-2. Prostaglandin E2: vasodilator

III. INCREASE PERMEABILITY:
2. ANP (atrial naturetic peptide): released by atria in response to stretch (from fluid overload). INCREASES GFR by increasing capillary surface area for increased filtration

42
Q

(41)

by what methods is GFR regulated?

A 
(41)
by what methods is GFR regulated?
1. neurologically
2. hormonally
3. intrinsic autoregulation
43
Q

(41)

how is GFR neurologically (and what parts of the kidneys are innvevated)?

A

(41)
how is GFR controlled neurologically (and what parts of the kidneys are innvevated)?
-1. sympathetic nerve innervation to afferent and efferent arterioles to vasoconstrict blood coming into kidney or leaving.
-2. during hemorrhage or exercise, sympathetic innervation (which is normally low) increases and shunts blood to other body parts.

44
Q

(42)
what happens in the kidneys when there is decreased arterial blood flow going into the kidneys ((afferent blood flow)? (7 things):

A

(42)
what happens in the kidney when there is decreased arterial blood flow going into the kidneys ((afferent blood flow)? (7 things):
-1. decreased arterial pressure
-2. decreased glumerular hydrostatic pressure
-3. decreased GFR
-4. decreased sodium to macula densa
-5a. increased renin release> increased angiotensin II
-5b. decreased afferent arteriole resistance
-6a. increased efferent arteriole resistance
-6b. decreased afferent arteriole resistance (cont.)
-7. leads to increased glumerular filtration

45
Q

(43)

what 4 hormones are secreted by the kidneys?

A

(43)
what 4 hormones are secreted by the kidneys?
1. renin
2. erythropoetin
3. aldosterone
4. Prostaglandins (P2G vasodilates; thromboxane vasoconstricts)

46
Q

(44)
acid base regulation of the kidneys:
how is it achieved?

A 
(44)
acid base regulation of the kidneys:
how is it achieved?
1. secretion of bicarbonate
2. distal convoluted tubule secretes H+ ions AGAINST concentration gradient
47
Q

(45)

  1. what are the sections of the loop of henle?
  2. what does each section do?
A

(45)

  1. what are the sections of the loop of henle?
    - a) descending limb (thick then thin)
    - b) ascending limb (thin then thick)
  2. what does each section do?
    - a) descending loop—Na+/Cl- diffuse OUT OF LUMEN along with H2O; this establishes a HYPER-OSMOTIC state causing a counter current exchange system (WATER IS REABSORBED OUT OF LUMEN)
    - b) ascending loop—active transport of Na+/Cl- OUT OF LUMEN which is impermeable to H2O so that water stays inside the lumen. this creates a HYPO-OSMOTIC fluid in the lumen and a HYPER-OSMOTIC fluid in the interstitium (outside the lumen) (SODIUM/CHLORIDE IS REABSORBED OUT OF LUMEN)
48
Q

(46)

  1. what causes the release of these renal hormones?
  2. what are the functions of these hormones?
A

(46)

  1. what causes the release of these renal hormones?
    - a. renin: released by the juxtoglomerular complex in response to:
    - - lack of stimulation of baroreceptors (hypovolemia)
    - - lack of sodium content in ultrafiltrate (sampled by macula densa)
    - - sympathetic stimulation (mainly B1)
    - b. erythropoetin: Hypoxemia
    - c. aldosterone: synthesized in zona glumerulosa and secreted in the presence of:
    - - hypovolemia (when atrial stretch receptors dont fire)
    - - angiotensin II;
    - d. Prostaglandins:
    - -P2G:
    - -thromboxane:
  2. what are the functions of these hormones?
    - a. renin:
    - b. erythropoetin: stimulates maturation of RBCs
    - c. aldosterone: causes distal convoluted tubule and collecting ducts to reabsorb or maintain sodium with water following (and excrete K+) to increase volume
    - d. Prostaglandins:
    - -P2G: direct vasodilator on smooth muscle; also inhibits release of norepinephrine (noradrenalin)
    - -thromboxane: formed from eicosinoids, cause vasoconstriction
49
Q

(47)

what does the proximal convoluted tubule do?

A

(47)
what does the proximal convoluted tubule do?
-reabsorbs the bulk of fluid and contents;
-active transport of Na+ and passive transport of Cl-
-transport of H2O, electrolytes and organic substances
-H+ ions are actively transported (from blood into PCT)in exchange for Na+

50
Q

(48)

what is the job of the distal convoluted tubule?

A

(48)
what is the job of the distal convoluted tubule?
-Na+ is reabsorbed in the presence of aldosterone
-K+ is excreted (in exchange for Na+)
-H+ is secreted against the concentration gradient to regulate acid/base balance
-H20 permeability is controlled by ADH

51
Q

(49)

what are the parts of the nephron?

A 
(49)
what are the parts of the nephron?
a. glomerulus
b. glumerular capsule
c. renal tubule (PCT, loop of henle, DCT)
d. collecting duct
52
Q

(50)

  1. what is the function of the nephron?
  2. how many nephrons per kidney?
A

(50)

  1. what is the function of the nephron?
    - - the nephron is the functional unit of the kidneys, filters water, small molecules such as salt, glucose, urea, drugs, and other small molecules (proteins are too large to pass thru)
  2. how many nephrons per kidney?
    - - 1 million per kidney
53
Q

(51)

Function of aldosterone

A

(51)
Function of aldosterone
–Aldosterone is secreted by the adrenal cortex in response to Na+ and K+ levels in the ECF and by renin-angiotensin (in response to hypovolemia)
–causes the reabsorption of Na+ (so that water follows) from the distal convoluted tubule and collecting duct causing increased blood volume. trades K+ for sodium so that potassium is excreted.

54
Q

(52)
A. function of Renin (the whole cascade):
B. function of angiotensin II:

A

(52)
A. function of Renin (the whole cascade):
–renin is secreted in response to decreased perfusion (hydrostatic pressure). Renin enters the blood and cleaves angiotensin-ogen (made in the liver) into angiotensin which goes to the lungs and is converted to angiotensin II
B. function of angiotensin II:
–angiotensin II is a potent vasoconstrictor in the kidneys and systemically

55
Q

(53)

  1. function of ADH
  2. what else causes secretion of ADH?
A

(53)

  1. function of ADH
    - -ADH is secreted in response to hyperosmotic ECF. If the electrolyte concentration is too high, that means you are dry. anti diuretic hormone causes fluid retention by blocking diuresis, this increases volume.
    - - ADH increases tubular permeability causing H2O reabsorption.
  2. what else causes secretion of ADH?
    - -ADH secretion is also triggered by pain, stress as well as hypotension
56
Q
  1. function of Vitamin D
A
  1. Vitamin D is converted to active form by the enzymes in the kidney;
    - the active form (actually a hormone) helps the intestines to reabsorb Ca++
  2. persons with renal disease are at risk for hypocalcemia
57
Q
  1. function of erythropoetin:

2. what happens in renal patients?

A
  1. erythropoetin is secreted by the kidneys and stimulates the bone marrow to cause maturation of RBCs
  2. renal patients are prone to anemia.
58
Q
  1. what is the best IV (induction or TIVA) anesthesia for a renal patient?
  2. what IV anesthesia is usually not used?
A

what is the best anesthesia for a renal patient?

  • a. remifentanil: is the best d/t quick on and off (undergoes hydrolysis in the blood by plasma esterase)
  • b. if no remifentanil, small amounts of fentanyl and very small amounts of versed or possibly ativan
  • c. ketamine 1-4.5 mg/kg or etomidate 0.1-0.3 mg/kg (d/t cardiovascular stability)
    2. what IV anesthesia is usually not used?
  • propofol-causes vasodilation, cardiac suppression
59
Q

what is the best inhaled anesthesia?

A

no significant difference but sevo does have flourine ion bi products (toxic threshold of 50 mmol rarely reached)

60
Q
  1. what are the best paralytics for renal patients?

2. what are the least desirable MRs for renal patients?

A
  • a. cisatricurium (nimbex) [or atricurium (mivacron)-not available]- both undergo ester hydrolysis and hoffman elimination
  • b. succinylcholine (check K+ first)- may increase K+ with muscle stimulation (Na+ ions (in) and exchange for K+ (out) ions with depolarization)
    2. what are the least desirable MRs for renal patients?
  • a. pavulon has such a long halflife
  • b. vecuronium has a moderate duration of action and is 70% renal excreted
  • c. rocuronium has a slightly shorter duration of action and is 70% renal excreted
61
Q

blood flow into the kidneys (review):

  1. blood enters the nephron via the ____?
  2. blood vessels then form the _____?
  3. blood leaves the nephron via the ____?
A

blood flow into the kidneys (review):

  1. blood enters the nephron via the afferent vessel?
  2. blood vessels then form the glumerulus?
  3. blood leaves the nephron via the efferent vessels?

1. adv principles 3 exam 1 (3 decks)

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