renal Flashcards
1
Q
kidneys are located ________________ with the __________ kidney being lower than the other
A
retroperitoneal; right
2
Q
pain from the kidney is transmitted via _______________ sympathetic fibers
A
T10-L1 SNS
3
Q
parasympathetic innervation of the kidneys
A
Vagus via S2 - S4
4
Q
pain innervation to the bladder
A
T11-L2
5
Q
motor/stretch, parasympathetic innervation to the bladder
A
S2-S4
6
Q
if doing neuraxial block for kidney surgery would want coverage from _____________
A
T8-L4
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
8
Q
where are the renal pyrimids housed
A
renal medulla
9
Q
______________ & _____________ are in the renal medulla and they channel urine to the renal pelvis –> ureters
A
major calyx; minor calyx
10
Q
RBF to the nephron is _______% of CO = _____________ mL/min
A
20; 1100
11
Q
what is normal GFR for a 70 kg male
A
125 ml/min
12
Q
the nephron makes ___________ml/day of filtrate and __________L/day excreted as urine
A
180; 1
13
Q
kidneys filter _______x TBW/day
A
4
14
Q
formula for RBF =
A
(MAP - VP) x VR
15
Q
what is the primary site of reabsorption in the nephron
A
PCT
16
Q
what are the 4 primary fx of the nephron
A
- filtration 2. absorption 3. secretion 4. excretion
17
Q
what the kidneys excrete = ____________ - ___________ + ______________
A
filtration; reabsorption; secretion
18
Q
what is the primary site of water movement in the nephron
A
Descending loop (b/c that is where aquaporins are)
19
Q
where does filtration begin in the nephron
A
glomerulus @ afferent arteriole
20
Q
what is a normal creatine clearance
A
125 ml/min
21
Q
about ______% of renal blood flow is the ________________
A
55%;renal plasma flow
22
Q
what is normal renal plasma flow
A
625 ml/min
23
Q
what is filtered from the glomerulus to bowmans capsule
A
- water 2. salt3. glucose 4. urea
24
Q
__________% of plasma fluid is reabsorbed in the kidneys
A
99
25
what is secreted (into the tubules for excretion) in the kidneys
1. H+ 2. K+ 3. ammonia 4. certain drugs
26
what are the pressures in the glomerulus
1. capillary hydrostatic pressure (pushes fluid out of the capillary) 2. capillary colloid oncotic pressure (holds fluid in the capillary)
27
what are the pressures in bowmans capsule
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
28
formula for net filtration pressure
glomerular hydrostatic pressure - bowmans capsule pressure - glomerular oncotic pressure
29
what is a normal net filtration pressure
10 mmHg
30
_________________ is the most porous capillary network in the body
glomerulous
31
the membrane layers of the glomerulus are __________ charged and NO ___________ are allowed to be filtered through
negatively; protein
32
what are the three major membrane layers of the glomerulus
1. endothelium 2. basement membrane 3. epithelial cells
33
_____________ is a layer of the glomerulus membrane that is fenestrae, negatively charged, but wont allow proteins through
endothelium
34
______________ is a membrane layer of the glomerulus that filters water and small solutes, consists of negatively charged glycoproteins, and does not allow proteins through
basement membrane
35
_____________ is also called podocytes
epithelial cells (of glomerulus)
36
what is allowed to be freely filtered through the glomerulus
1. water 2. Na 3. glucose 3. insulin
37
autoregulation of the kidney is done between MAP of ________-________
50; 150
38
T/F: UOP is autoregulated in the kidney
FALSE
39
when renal perfusion is low, autoregulation will _____________ renal vascular resistance
decrease
40
when renal perfusion is high, autoregulation will _____________ renal vascular resistance
increase
41
when MAP is < 50 or > 150, ________________ will modulate the afferent and efferent arterioles to keep flow adequate through the kidneys
local feedback signals
42
what are the theories regarding local feedback signals in the kidneys
1. myogenic theory 2. tubuloglomerular theory
43
what is the myogenic theory
1. theory of local feedback to keep flow through the kidneys2. muscle stretch via ion channel depolarization
44
tubuloglomerular theory
local feedbakc that links Cl concentration at the macula desna and contrls the renal arterial resistance and autoregulation of GFR
45
______________ is a secondary regulation of maintaining flow through the kidneys until an acute sympathetic stimulus and vasoconstriction occurs
neural regulation
46
primary fx's of the renal system
1. excrete end products of metabolism 2. retain nutrients 3. maintain volume and composition of the body
47
secondary fx of the renal system
1. Epo production 2. conversion of Vitamin D to active form 3. calcium conservation via activity PTH 4. peptide and protein hormone metabolism
48
what is the most reliable measure of kidney function
creatinine clearance
49
____________ is the volume of blood plasma that is cleared of creatinine per unit of time
creatinine clearance
50
pre-renal AKI is the cause of acute renal failure __________% of the time
60
51
what is the cause of pre-renal AKI
renal hypoperfusion
52
intra-renal AKI is the cause of acute renal failure __________% of cases
30
53
what causes intrarenal AKI
1. abnormalities within the kidney itself (blood vessels, glomeruli or tubules)2. Acute Tubular Necrosis
54
______________ is the destruction of epithelial cells in the tubules of the kidneys
acute tubular necrosis
55
what causes acute tubular necrosis
1. acute glomerulonephritis 2. acute pyelonephritis 3. IV contrast 4. aminoglycosides 5. fluoride ions 6. inflammatory injury/ischemia 7. toxic drugs
56
postrenal AKI is the cause of acute renal failure ______% of cases
<10
57
what is the cause of postrenal AKI
obstruction of the urinary collecting system from calyces to outflow of the bladder
58
ureter obstruction/kidney stones would lead to which type of AKI?
postrenal
59
what systemic diseases would be high risk for renal procedures?
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
what are high risk procedures for the renal pt
1. if any procedure exposes the pt to nephrotoxic drugs 2. CPB3. Ao cross clamp 4. pneumoperitoneum 5. emergency surgery
61
___________ is an independent risk factor for CAD
CKD
62
H&P of the renal pt
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
H & P of the dialysis pt
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
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
5.5.; 6-6.5
65
what to do about hyperkalemia in the CKD pt DOS?
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
what to do for uremic bleeding intraop with the CKD pt
give DDAVP
67
what is uremic bleeding in the CKD patient from?
impaired plt function
68
preop lab testing in the CKD pt
1. electrolytes2. H/H3. BUN/Cr 4. Cr clearance/GFR5. coags 6. serum and urine albumin
69
when would you consider preop CXR in the CKD pt?
if suspicion of pericardial or pleural effusions
70
when would an EKG be indicated in the CKD pt preoperatively?
1. if Cr > 2.0 (increased risk for cardiac event) 2. hyperkalemia
71
when would you consider preop echo in pt with CKD
#NAME?
72
when would you consider a preop stress test on the CKD pt?
if they also have CAD
73
pre-anesthesia risk reduction for the renal pt
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
strategies to prevent AKI
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
what has no benefit in preventing AKI
1. renal dose dopamine 2. Diuretics
76
what is the goal in IVF management for renal failure
to preserve existing renal function, maximize renal perfusion, and not cause further decompensation
77
what is the ideal UOP for non-renal pts
0.5 - 1 ml/kg/hr
78
IVF management in renal failure
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
T/F: LR is avoided in to replace 3rd space losses in renal pts
true; contains 4 mEq/L of K+ so avoid in renal pts
80
what are the most common causal factors of AKI
hypotension and hypovolemia
81
how does anesthesia and surgery --> decreased RBF, GFR, urine flow, and Na excretion?
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
anesthetic management considerations of the renal failure pt
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
what opioids should you avoid with renal pts
1. morphine 2/2 morphine-6-glucuronide AM
84
considerations with reversal agents in Renal pts
1. Antichol (atropine glycopyrolate) - accumulates with RF 2. edrophonium, neostigmine, and pyridostigmine are renally excreted --> long 1/2 life
85
what opoids would be best choice for renal pts
phenylpiperidines (fentanyl, remifentanil, sufentanil)
86
T/F: ketamine minimally affects renal fx
TRUE
87
Tordol effect on kidneys (renal pt)
inhibition of prostaglandins --> inhibits afferent arteriole dilation --> decreased GFR
88
ACE I effect on kidneys (renal pt)
further decrease GFR 2/2 blocking ATII
89
what ABX will decrease renal fx
1. aminoglycocides (gentamycin, neomycin) 2. amphotercin B
90
which abx are typically nephrotoxic
-mycins
91
when is it safe to use succ in a renal pt?
if K is less than 5.5
92
with succinylcholine in a renal pt, you should know it will increase their serum K+ by __________ mEq/L
0.5
93
considerations of vecuronium and rocuronium in the renal pt
primarily excreted via liver, but 20% excreted in the kidney (may have some prolonged effect)
94
pancuronicum consideration in renal pts
60-90% excreted in the kidneys
95
what are your muscle relaxants of choice for renal pts
1. cisatracurium2. atracurium 3. mivacurium
96
why is cisatracurium, atracurium, and mivacurium the muscle relaxants of choice in renal pts
they are metabolized/excreted via ester metabolism and hoffman elimination only (no kidney involvment)
97
ALL volatile agents have what effect on the kidneys
decrease RBF/GFR and UOP
98
volatiles that breakdown to inorganic fluoride are at increased risk of renal impairment if doses > _____ MAC are used for > _______ hours
1.0; 2
99
sevoflurane if used in renal pts should be at FGF > _______ L/min to minimize accumulation of _____________
2; compound A
100
__________________ (in certain volatiles) is 70% metabolized into _____________ which is renal toxic
methoxyflurane; inorganic fluoride
101
what position is frequently used in urinary/renal procedures
lithotomy
102
a common position with renal/kidney procedures is lithotomy, what are the considerations with this position?
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
common nerve injuries with lithotomy (commonly used in renal/urinary procedures)
1. common peroneal 2. saphenous nerve 3. obturator 4. femoral 4. T10 sensory level
104
post renal procedure, the patient cannot dorsiflex foot, lithotomy position was used, what do you think has occured
common peroneal nerve damage
105
post op renal procedure pt is complaining of numbness along the inside calf, lithotomy position was used intraop - what do you think has occured
saphenous nerve injury
106
post op renal/urinary procdure pt has excessive flexion of the thigh, lithotomy position was used intraop, what do you think has occurred?
obturator and/or femoral nerve injury
107
considerations with a nephrectomy
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
______________ nephrectomy, they take a piece of the kidney, __________ nephrectomy, they take the majority of the kidney and the vessels that surround it
partial; radical
109
radical nephrectomy is done for _________ (90% of cases) or ___________ type cancers of the kidney
renal cell carcinoma; transitional cell carcinoma
110
if a renal tumor extends into the intrahepatic IVC, what other things should you take into consideration?
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
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
ileal conduit; neobladder
112
complications of cystectomy
1. infection 2. pouch leakage 3. bowel obstruction 4. malabsorption 5. electrolyte abnormalities
113
what electrolyte abnormalities may occur with cystectomy?
1. hyperchloremic metabolic acidosis 2. hypokalemia 3. hypomagnesemia 4. hypocalcemia
114
older white man with smoking hx and transitional cell carcinoma will often have a ___________ cystectomy
radical - removal of sex organs + bladder
115
simple cystectomy is common for what
1. interstitial cystitis 2. neurogenic bladder
116
preoperative considerations with a prostatectomy
1. assessment of comorbid conditions 2. pain management 3. monitoring
117
what are the different transurethral procedures that are done?
1. transurethral cystoscopy2. transurethral urteteroscopy (+ stent) 3. TURP4. TURBT
118
anesthetic techniques with transurethral procedures
1. if do neuraxial need coverage T8 - T10 2. GA (ETT or LMA)
119
intraoperative management of transurethral procedures
1. temperature management2. difficult to assess blood loss 3. watch for complications like extraperiotneal fluid extravasion or bladder perforation
120
postop anesthetic management of transurethral procedure
monitor need for transfusion/serious bleeding
121
______________ cautery causes TURP syndrome most often bc you have to use a non-electrolyte irrigation solution
unipolar
122
TURP syndrome
absorption of irrigation fluid into the vascular system during resection
123
Tx of turp syndrome
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
absolute contraindications for shock wave lithotripsy
1. bleeding d/o 2. pregnancy
125
relative c/i for shock wave lithotripsy
1. pacers/ICDs 2. significant Ao Disease
126
extracorpeal shock wave lithotripsy it is important to ____________ shock waves to avoid R on T
sync
127
complications of extracorpeal shock wave lithotripsy
1. hypothermia with water bath 2. dysrythmias (R on T) 3. kidney injury
