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Co-Existing Disease > Renal > Flashcards

Renal Flashcards

1
Q

These factors will result in prostaglandin synthesis by the kidneys

A

Renal ischemia, renal hypotension, and physiological stress

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2
Q

This common drug used for post-op pain relief should be avoided in those at risk for medullary ischemia. Why?

A

Ketorolac (Toradol)

This is because it is a powerful NSAID, which drastically reduces prostaglandin synthesis, putting the kidneys at risk for ischemia

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3
Q

Low dose dopamine will do this, but not this

A

Will have positive inotropic effects, which increase UO.

Will not decrease the incidence of ARF, dialysis, or mortality

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4
Q

The kidneys are able to autoregulate over this range of MAPs

A

80-180
Some say up to 200

Either way, kidneys are very sensitive to a reduction in MAP
Also, may be higher than 80 if the patient has chronic HTN

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5
Q

Surgical stimulation can cause release of this hormone

A

ADH

This will cause a drop in UO

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6
Q

This will cause aldosterone release

A

baroreceptor response to volume depletion

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7
Q

In hypotension, blood will be shunted (towards/away) from the kidneys

A

Away from the kidneys! Towards the vital organs

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8
Q

What ion are we concerned about in renal failure?

A

Floride. Free fluoride ions cause tubular injury and loss of concentrating ability (can result in ARF)

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9
Q

Ranking of volatile agent effects on the kidney

A

Methoxy>Enflu>Sevo>Iso>Des>Halo

MESID H

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10
Q

We prefer the use of these IAs in renal failure patients

A

Iso and des

These have negligible effects on renal function

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11
Q

This is the minimum amount of gas flow that should be given with Sevo

A

2L to prevent compound A formation

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12
Q

BUN > ___ is indicative of decreased GFR

A

50

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13
Q

These factors may cause GFR to rise despite a normal GFR

A

High protein diet
GI bleed
Febrile illness
Dehydration

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14
Q

What is the most common cause of high BUN

A

CHF secondary to the reabsorption of BUN
Low CO causes lows kidney perfusion.
Kidneys try to correct perceived fluid deficit by reabsorbing urea.

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15
Q

There is a __-__ hour lag time after a change in GFR before the increase creatinine levels are seen

A

8 - 17

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16
Q

What test is the most reliable estimate of GFR?

A

Creatinine clearance

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17
Q

Why is anemia common in renal failure?

A

1) Decreased EPO production

2) Build-up of toxins decreases the lifespan of RBCs

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18
Q

Chronic renal patients will usually have an increased or decreased CO?

A

Increased to compensate for the anemia

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19
Q

Hemoglobin levels as low as __-__ are common for renal patients, so don’t freak out

A

5-8

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20
Q

Renal patients usually have fucked up coags. Which coags are fucked up and why?

A

PT, PTT, and bleeding time.

These are fucked up because they have shitty vWF. Treat this by replacing vWF.

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21
Q

How can you treat the fucked up coags seen in renal dysfunction?

A

Replace the vWF!

1) Desmopressin .3-.4mg/kg over 30 min)
- Desmopressin will increase the release of vWF from endothelial cells

2) Cryoprecipitate (remember that this contains factor VIII, XIII, fibrinogen, and whaddup –> vWF!)

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22
Q

The hyperkalemia seen in RF can result in these EKG changes

A

Peaked T waves, ST depression, prolonged PR interval and QRS complex, heart block, and V-fib

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23
Q

Hypermagnesemia resulting from RF can cause

A

Coma and CNS depression

Prolongs the duration of NMBs

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24
Q

Why do we use a microdripper to give fluids in renal patients?

A

To make sure we don’t fluid overload them

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25
Q

Why does RF cause HTN?

A

1) Renin release by the diseases kidney

2) High intravascular fluid volume d/t inappropriate handling of sodium and water

26
Q

RF can lead to ____ pericarditis and cause

A

uremic pericarditis

tamponade

27
Q

Hypocalcemia causes this on EKG

A

Prolonged QT

28
Q

Digitalis toxicity produces this on EKG

A

Shortened QT and depressed ST

29
Q

These meds are excreted via the kidneys unchanged and are contraindicated in RF

A

Gallamine (100% renal elimination) and phenobarbital

30
Q

Is UO predictive of post-op renal insufficiency?

A

No

31
Q

What can happen if you give too much fluid to your anuric renal patients?

A

CHF and pulmonary edema

32
Q

UO during surgery should be maintained at this rate

A

0.5cc/kg/min

If it falls, we can give 5mg of lasix

33
Q

A 50% increase in plasma creatinine means

A

A 50% reduction in GFR

34
Q

This is the source of creatinine

A

Skeletal muscle

35
Q

We are concerned about K+ when it is over

A

5

36
Q

When is vasopressin released?

A

Released by the posterior pituitary in response to high serum osmolarity and acts on the kidneys

37
Q

This is the dose for low-dose dopamine

A

1-2mcg/kg/min

38
Q

Effect of neuraxial anesthesia in renal dysfunction

A

• T4-T10 sympathectomy will decrease the release of catecholamines, renin, and vasopressin (ADH)
o This is because we’re causing vasodilation and blocking the sympathetic response!
o Make sure to pre-hydrate before placement!
• Key to maintenance of renal blood flow and GFR is you have to maintain renal perfusion pressure – fluid boluses etc.
o Remember that proper RBF is dependent on MAP

39
Q

Effect of PPV on renal function, and how we can over come this

A

• The higher the PIP and PEEP the greater the decrease in RBF, GFR, and urine flow rate
o Probably because PPV will decrease venous return and CO

We can overcome this by hydrating.

40
Q

Creatinine Clearance

A

Normal is 125mL/min
• < 25 ml/min indicates moderate disease.
• < 10 ml/min indicates the patient is anephric and need hemodialysis.
• Disadvantage of test: Urine needs to be collected over 2 to 24 hours, depending on the lab’s capabilities; rely on patient compliance also an issue.

41
Q

What may a CXR show in the patient with renal failure?

A

• LVH
o Determine presence of hypertensive cardiovascular disease
• Pericardial effusion (from uremic pericarditis)
• Uremic pneumonitis- RF patients have chronic pulmonary edema → fluid overload, shitty heart function, and leaky capillaries

42
Q

Avoid these NMBs in renal failure

A

d-tubocurarine, metocurine, gallamine

43
Q

What is the most common cause of death in renal failure?

A

Infection

Make sure to use aseptic technique!!

44
Q

IAs for RF

A

 Halothane
 Avoid- High K+ & acidosis-> myocardial irritability
 Enflurane
 Avoid- fluoride concern
 Sevoflurane
 Controversial: some practitioners remain concerned regarding Compound A and fluoride
 Isoflurane/Desflurane
 Volatile agents ideal-no dependence on kidney for elimination
 Accelerated induction and emergence seen with severe anemia
 Anemia results in decreased solubility of the IA

45
Q

Ventilation goals in RF

A

 Hypoventilation exacerbates acidosis
 Hypercapnia predisposes to cardiac arrhythmias from acidosis
 Alkalosis shifts oxy-hgb curve to left- less O2 available to tissues
 Overall, we want to maintain normal acid/base balance
 Remember too that they are anemic and we want to do this to keep the O2 dissociation curve to the right!!

Remember that high PIP and PEEP will decrease RBF

46
Q

This is the pressor of choice for renal pts

A

Ephedrine

47
Q

What’s the deal with H2 blockers and renal failure?

A

H2 blockers are highly dependent on renal excretion

48
Q

When does cystoscopy require more than local anesthesia?

A

If the bladder if being inflated (consider RA or GA)

49
Q

Lithotomy position for cystoscopy puts you at risk for these nerve injuries

A

All major legs nerves except LFC

Sciatic, common peroneal, femoral, saphenous, and obturator

50
Q

RA for cystoscopy

A

Need T10 block
Spinal preferred d/t brief nature of the surgery
Will not abolish the obturator reflex (can only be blocked by muscle relaxants, which we don’t use with a regional technique)

51
Q

GA for cystoscopy

A 
Short case (15-20 min)
LMA ok to use
52
Q

S/S associated with TURP syndrome

A

headache, restlessness, confusion, seizure, dyspnea, cyanosis, arrhythmias, hypotension with bradycardia

53
Q

Irrigating fluids used for TURP

A

glycine, sorbitol, or mannitol

54
Q

How to prevent TURP syndrome

A

Limit irrigating fluid height to 40cm above prostate (job of the urologist)
Limit resection time to less than 1 hour

55
Q

Treatment for TURP syndrome

A

EARLY DETECTION!!
 Fluid restriction
 Loop diuretic
 To correct fluid overload and hyponatremia
 Hypertonic solution if hyponatremia present. 100cc 3% saline over 1-2 hours. Administer based on patients serum sodium (Ideally >120)
 Hyponatremia occurs d/t large absorption of this fluid that doesn’t contain lytes
 Results in cerebral edema
 Treat seizures with midazolam, thiopental or phenytoin (if glycine used consider a trial of magnesium)
 Intubate if pulmonary edema has occurred (from volume overload)

56
Q

Regional blockade level needed for ESWL

A

T6

57
Q

Why is GA preferred for ESWL?

A

Ability to control diaphragmatic excursion (Jet ventilation)

58
Q

Coagulation considerations in RF

A

o Increased bleeding despite normal PT, PTT, and Bleeding Time
• Caused by release of defective von Willebrand factor
• Rx- Desmopressin (0.3-0.4 mg/kg over 30 min) or cryoprecipitate
o Blood warmer- set up and have ready to go

59
Q

When is vasopressin released?

A

It’s released by the posterior pituitary in response to an increase in serum osmolarity

60
Q

Something to remember before doing neuraxial anesthesia in renal failure

A

• T4-T10 sympathectomy will decrease the release of catecholamines, renin, and vasopressin (ADH)
o This is because we’re causing vasodilation and blocking the sympathetic response!
o Make sure to pre-hydrate before placement!

Co-Existing Disease (10 decks)

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