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principles II: burns, renal, trauma, liver > renal > Flashcards

renal Flashcards

1
Q

kidneys are located ________________ with the __________ kidney being lower than the other

A

retroperitoneal; right

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2
Q

pain from the kidney is transmitted via _______________ sympathetic fibers

A

T10-L1 SNS

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3
Q

parasympathetic innervation of the kidneys

A

Vagus via S2 - S4

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4
Q

pain innervation to the bladder

A

T11-L2

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5
Q

motor/stretch, parasympathetic innervation to the bladder

A

S2-S4

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6
Q

if doing neuraxial block for kidney surgery would want coverage from _____________

A

T8-L4

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7
Q

__________________ is the concave area of the kidney where all the blood enters/exists the kidney and where the ureters exit to the bladder

A

hilum

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8
Q

where are the renal pyrimids housed

A

renal medulla

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9
Q

______________ & _____________ are in the renal medulla and they channel urine to the renal pelvis –> ureters

A

major calyx; minor calyx

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10
Q

RBF to the nephron is _______% of CO = _____________ mL/min

A

20; 1100

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11
Q

what is normal GFR for a 70 kg male

A

125 ml/min

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12
Q

the nephron makes ___________ml/day of filtrate and __________L/day excreted as urine

A

180; 1

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13
Q

kidneys filter _______x TBW/day

A

4

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14
Q

formula for RBF =

A

(MAP - VP) x VR

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15
Q

what is the primary site of reabsorption in the nephron

A

PCT

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16
Q

what are the 4 primary fx of the nephron

A
  1. filtration 2. absorption 3. secretion 4. excretion
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17
Q

what the kidneys excrete = ____________ - ___________ + ______________

A

filtration; reabsorption; secretion

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18
Q

what is the primary site of water movement in the nephron

A

Descending loop (b/c that is where aquaporins are)

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19
Q

where does filtration begin in the nephron

A

glomerulus @ afferent arteriole

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20
Q

what is a normal creatine clearance

A

125 ml/min

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21
Q

about ______% of renal blood flow is the ________________

A

55%;renal plasma flow

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22
Q

what is normal renal plasma flow

A

625 ml/min

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23
Q

what is filtered from the glomerulus to bowmans capsule

A
  1. water 2. salt3. glucose 4. urea
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24
Q

__________% of plasma fluid is reabsorbed in the kidneys

A

99

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25
Q

what is secreted (into the tubules for excretion) in the kidneys

A
  1. H+ 2. K+ 3. ammonia 4. certain drugs
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26
Q

what are the pressures in the glomerulus

A
  1. capillary hydrostatic pressure (pushes fluid out of the capillary) 2. capillary colloid oncotic pressure (holds fluid in the capillary)
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27
Q

what are the pressures in bowmans capsule

A
  1. interstitial hydrostatic pressure (pushes fluid out of interstitium) 2. interstitial oncotic pressure (pulling fluid into the interstitium) ~18 mmHg = total pressure within bowmans capsule
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28
Q

formula for net filtration pressure

A

glomerular hydrostatic pressure - bowmans capsule pressure - glomerular oncotic pressure

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29
Q

what is a normal net filtration pressure

A

10 mmHg

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30
Q

_________________ is the most porous capillary network in the body

A

glomerulous

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31
Q

the membrane layers of the glomerulus are __________ charged and NO ___________ are allowed to be filtered through

A

negatively; protein

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32
Q

what are the three major membrane layers of the glomerulus

A
  1. endothelium 2. basement membrane 3. epithelial cells
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33
Q

_____________ is a layer of the glomerulus membrane that is fenestrae, negatively charged, but wont allow proteins through

A

endothelium

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34
Q

______________ is a membrane layer of the glomerulus that filters water and small solutes, consists of negatively charged glycoproteins, and does not allow proteins through

A

basement membrane

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35
Q

_____________ is also called podocytes

A

epithelial cells (of glomerulus)

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36
Q

what is allowed to be freely filtered through the glomerulus

A
  1. water 2. Na 3. glucose 3. insulin
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37
Q

autoregulation of the kidney is done between MAP of ________-________

A

50; 150

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38
Q

T/F: UOP is autoregulated in the kidney

A

FALSE

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39
Q

when renal perfusion is low, autoregulation will _____________ renal vascular resistance

A

decrease

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40
Q

when renal perfusion is high, autoregulation will _____________ renal vascular resistance

A

increase

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41
Q

when MAP is < 50 or > 150, ________________ will modulate the afferent and efferent arterioles to keep flow adequate through the kidneys

A

local feedback signals

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42
Q

what are the theories regarding local feedback signals in the kidneys

A
  1. myogenic theory 2. tubuloglomerular theory
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43
Q

what is the myogenic theory

A
  1. theory of local feedback to keep flow through the kidneys2. muscle stretch via ion channel depolarization
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44
Q

tubuloglomerular theory

A

local feedbakc that links Cl concentration at the macula desna and contrls the renal arterial resistance and autoregulation of GFR

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45
Q

______________ is a secondary regulation of maintaining flow through the kidneys until an acute sympathetic stimulus and vasoconstriction occurs

A

neural regulation

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46
Q

primary fx’s of the renal system

A
  1. excrete end products of metabolism 2. retain nutrients 3. maintain volume and composition of the body
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47
Q

secondary fx of the renal system

A
  1. Epo production 2. conversion of Vitamin D to active form 3. calcium conservation via activity PTH 4. peptide and protein hormone metabolism
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48
Q

what is the most reliable measure of kidney function

A

creatinine clearance

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49
Q

____________ is the volume of blood plasma that is cleared of creatinine per unit of time

A

creatinine clearance

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50
Q

pre-renal AKI is the cause of acute renal failure __________% of the time

A

60

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51
Q

what is the cause of pre-renal AKI

A

renal hypoperfusion

52
Q

intra-renal AKI is the cause of acute renal failure __________% of cases

A

30

53
Q

what causes intrarenal AKI

A
  1. abnormalities within the kidney itself (blood vessels, glomeruli or tubules)2. Acute Tubular Necrosis
54
Q

______________ is the destruction of epithelial cells in the tubules of the kidneys

A

acute tubular necrosis

55
Q

what causes acute tubular necrosis

A
  1. acute glomerulonephritis 2. acute pyelonephritis 3. IV contrast 4. aminoglycosides 5. fluoride ions 6. inflammatory injury/ischemia 7. toxic drugs
56
Q

postrenal AKI is the cause of acute renal failure ______% of cases

A

<10

57
Q

what is the cause of postrenal AKI

A

obstruction of the urinary collecting system from calyces to outflow of the bladder

58
Q

ureter obstruction/kidney stones would lead to which type of AKI?

A

postrenal

59
Q

what systemic diseases would be high risk for renal procedures?

A
  1. HTN 2. HF 3. DM 4. obesity 5. cirrhosis 6. infections (systemic and UTI)7. family hx of kidney dz, hx of AKI 8. autoimmune diseases (SLE)
60
Q

what are high risk procedures for the renal pt

A
  1. if any procedure exposes the pt to nephrotoxic drugs 2. CPB3. Ao cross clamp 4. pneumoperitoneum 5. emergency surgery
61
Q

___________ is an independent risk factor for CAD

A

CKD

62
Q

H&P of the renal pt

A
  1. cause of renal failure 2. extent of co-existing dz 3. what meds are they on - ACE & ARB? - need to be held DOS4. prior surgeries/anesthesia 5. dialysis hx 6. vascular access type 7. transfusion hx
63
Q

H & P of the dialysis pt

A
  1. last run of dialysis (recommended to have day before) 2. weight (pre and post) 3. electrolytes: cl, K, Na 4. are they anuric 5. type of dialysis 6. presence of fistula? - what arm?
64
Q

in the CKD patient a K < ___________ is okay for surgery; however if they are chronically btwn __________ without EKG changes, they are also good to go

A

5.5.; 6-6.5

65
Q

what to do about hyperkalemia in the CKD pt DOS?

A
  1. <5.5 ok to go 2. chronically btwn 6-6.5 without EKG changes DOS, okay to go 3. plan to monitor and treat if needed perioperatively 4. if at same day surgery center - consider moving to cardiac capable inpatient setting
66
Q

what to do for uremic bleeding intraop with the CKD pt

A

give DDAVP

67
Q

what is uremic bleeding in the CKD patient from?

A

impaired plt function

68
Q

preop lab testing in the CKD pt

A
  1. electrolytes2. H/H3. BUN/Cr 4. Cr clearance/GFR5. coags 6. serum and urine albumin
69
Q

when would you consider preop CXR in the CKD pt?

A

if suspicion of pericardial or pleural effusions

70
Q

when would an EKG be indicated in the CKD pt preoperatively?

A
  1. if Cr > 2.0 (increased risk for cardiac event) 2. hyperkalemia
71
Q

when would you consider preop echo in pt with CKD

A

NAME?

72
Q

when would you consider a preop stress test on the CKD pt?

A

if they also have CAD

73
Q

pre-anesthesia risk reduction for the renal pt

A
  1. cardiac evaluation for BP and fx’al capacity 2. Hold ACEI and ARB 3. maintain euvolemi and perfusion pressure 4. a line and volume responsiveness monitoring (CVP)5. limit duration of insult 6. avoid/monitor contrast induced nephropathy
74
Q

strategies to prevent AKI

A
  1. avoid diruetics 2. continue statins 3. N-acetylcystein and NaHCO3 for CIN prevention 4. precedex 5. use pressors 6. avoid hypochloremic acidosis (avoid 0.9% NS)
75
Q

what has no benefit in preventing AKI

A
  1. renal dose dopamine 2. Diuretics
76
Q

what is the goal in IVF management for renal failure

A

to preserve existing renal function, maximize renal perfusion, and not cause further decompensation

77
Q

what is the ideal UOP for non-renal pts

A

0.5 - 1 ml/kg/hr

78
Q

IVF management in renal failure

A
  1. HD recommended day before anesthesia 2. D5W or 0.45% NS 3. volume restriction intraop 4. replaced 3rd space losses with balanced salt solution 5. may require invasive monitors to evaluate fluid status
79
Q

T/F: LR is avoided in to replace 3rd space losses in renal pts

A

true; contains 4 mEq/L of K+ so avoid in renal pts

80
Q

what are the most common causal factors of AKI

A

hypotension and hypovolemia

81
Q

how does anesthesia and surgery –> decreased RBF, GFR, urine flow, and Na excretion?

A
  1. Hotn from VD and induction 2. light anesthesia –> SNS activation –> VC –> decreased RBF and GFR 3. stress response from surgical inciscion –> catecholamine release, ADH, ANGII –> Na retention and decreased RBF
82
Q

anesthetic management considerations of the renal failure pt

A
  1. careful selection of drugs and amounts - 2/2 decreased protein binding and acidosis 2. regional good choice if not coagulopathic 3. increased Vd 4. H2 blocker preop 5. std monitoring +/- aline, CVP, PAC
83
Q

what opioids should you avoid with renal pts

A
  1. morphine 2/2 morphine-6-glucuronide AM
84
Q

considerations with reversal agents in Renal pts

A
  1. Antichol (atropine glycopyrolate) - accumulates with RF 2. edrophonium, neostigmine, and pyridostigmine are renally excreted –> long 1/2 life
85
Q

what opoids would be best choice for renal pts

A

phenylpiperidines (fentanyl, remifentanil, sufentanil)

86
Q

T/F: ketamine minimally affects renal fx

A

TRUE

87
Q

Tordol effect on kidneys (renal pt)

A

inhibition of prostaglandins –> inhibits afferent arteriole dilation –> decreased GFR

88
Q

ACE I effect on kidneys (renal pt)

A

further decrease GFR 2/2 blocking ATII

89
Q

what ABX will decrease renal fx

A
  1. aminoglycocides (gentamycin, neomycin) 2. amphotercin B
90
Q

which abx are typically nephrotoxic

A

-mycins

91
Q

when is it safe to use succ in a renal pt?

A

if K is less than 5.5

92
Q

with succinylcholine in a renal pt, you should know it will increase their serum K+ by __________ mEq/L

A

0.5

93
Q

considerations of vecuronium and rocuronium in the renal pt

A

primarily excreted via liver, but 20% excreted in the kidney (may have some prolonged effect)

94
Q

pancuronicum consideration in renal pts

A

60-90% excreted in the kidneys

95
Q

what are your muscle relaxants of choice for renal pts

A
  1. cisatracurium2. atracurium 3. mivacurium
96
Q

why is cisatracurium, atracurium, and mivacurium the muscle relaxants of choice in renal pts

A

they are metabolized/excreted via ester metabolism and hoffman elimination only (no kidney involvment)

97
Q

ALL volatile agents have what effect on the kidneys

A

decrease RBF/GFR and UOP

98
Q

volatiles that breakdown to inorganic fluoride are at increased risk of renal impairment if doses > _____ MAC are used for > _______ hours

A

1.0; 2

99
Q

sevoflurane if used in renal pts should be at FGF > _______ L/min to minimize accumulation of _____________

A

2; compound A

100
Q

__________________ (in certain volatiles) is 70% metabolized into _____________ which is renal toxic

A

methoxyflurane; inorganic fluoride

101
Q

what position is frequently used in urinary/renal procedures

A

lithotomy

102
Q

a common position with renal/kidney procedures is lithotomy, what are the considerations with this position?

A
  1. decreases FRC 2. INcrease: preload, BP, SVR 3. pad leg supports 4. 2 people needed to move legs up and down out of stirrups 5. check fingers 6. do NOT extubate with pt still in lithotomy
103
Q

common nerve injuries with lithotomy (commonly used in renal/urinary procedures)

A
  1. common peroneal 2. saphenous nerve 3. obturator 4. femoral 4. T10 sensory level
104
Q

post renal procedure, the patient cannot dorsiflex foot, lithotomy position was used, what do you think has occured

A

common peroneal nerve damage

105
Q

post op renal procedure pt is complaining of numbness along the inside calf, lithotomy position was used intraop - what do you think has occured

A

saphenous nerve injury

106
Q

post op renal/urinary procdure pt has excessive flexion of the thigh, lithotomy position was used intraop, what do you think has occurred?

A

obturator and/or femoral nerve injury

107
Q

considerations with a nephrectomy

A
  1. is it partial, simple, radical 2. open vs laparoscopic 3. preop testing: T&C, bleeding risk 4. 2 lg bore IVs 5. TOF (will be paralyzed) 6. post pain management 7. plan for potential complications
108
Q

______________ nephrectomy, they take a piece of the kidney, __________ nephrectomy, they take the majority of the kidney and the vessels that surround it

A

partial; radical

109
Q

radical nephrectomy is done for _________ (90% of cases) or ___________ type cancers of the kidney

A

renal cell carcinoma; transitional cell carcinoma

110
Q

if a renal tumor extends into the intrahepatic IVC, what other things should you take into consideration?

A
  1. may do Ao XC and/or CPB 2. risk of emboli 3. signficiant bleeding risk (use bair hugger/warm fluids) 4. consider use of TEE
111
Q

both of these cystectomy surgeries a section of the bowel is used to create a pouch, but with a ________________ a stoma is created and with a _____________ a pouch is connected to native ureters

A

ileal conduit; neobladder

112
Q

complications of cystectomy

A
  1. infection 2. pouch leakage 3. bowel obstruction 4. malabsorption 5. electrolyte abnormalities
113
Q

what electrolyte abnormalities may occur with cystectomy?

A
  1. hyperchloremic metabolic acidosis 2. hypokalemia 3. hypomagnesemia 4. hypocalcemia
114
Q

older white man with smoking hx and transitional cell carcinoma will often have a ___________ cystectomy

A

radical - removal of sex organs + bladder

115
Q

simple cystectomy is common for what

A
  1. interstitial cystitis 2. neurogenic bladder
116
Q

preoperative considerations with a prostatectomy

A
  1. assessment of comorbid conditions 2. pain management 3. monitoring
117
Q

what are the different transurethral procedures that are done?

A
  1. transurethral cystoscopy2. transurethral urteteroscopy (+ stent) 3. TURP4. TURBT
118
Q

anesthetic techniques with transurethral procedures

A
  1. if do neuraxial need coverage T8 - T10 2. GA (ETT or LMA)
119
Q

intraoperative management of transurethral procedures

A
  1. temperature management2. difficult to assess blood loss 3. watch for complications like extraperiotneal fluid extravasion or bladder perforation
120
Q

postop anesthetic management of transurethral procedure

A

monitor need for transfusion/serious bleeding

121
Q

______________ cautery causes TURP syndrome most often bc you have to use a non-electrolyte irrigation solution

A

unipolar

122
Q

TURP syndrome

A

absorption of irrigation fluid into the vascular system during resection

123
Q

Tx of turp syndrome

A
  1. communicate with surgeon to stop surgery 2. O2, airway support 3. labs/ABG 4. if mild sx (Na > 120) = loop diuretic and fluid resitrction) 5. 3% saline if seizures of coma occur 6. tx seizure with versed, propofol, dilantin
124
Q

absolute contraindications for shock wave lithotripsy

A
  1. bleeding d/o 2. pregnancy
125
Q

relative c/i for shock wave lithotripsy

A
  1. pacers/ICDs 2. significant Ao Disease
126
Q

extracorpeal shock wave lithotripsy it is important to ____________ shock waves to avoid R on T

A

sync

127
Q

complications of extracorpeal shock wave lithotripsy

A
  1. hypothermia with water bath 2. dysrythmias (R on T) 3. kidney injury

principles II: burns, renal, trauma, liver (1 decks)

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