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AW > Renal > Flashcards

Renal Flashcards

1
Q

How to reduce contrast induced nephropathy?

A

Use less contrast

nonionic, iso-osmolar, low in viscosity contrast

antioxidant: NActeylcysteine, ascorbic acid

bicarb infusion to alkaline urine (3ml/kg/hr for 1 hr prior and 1ml/kg/hr for next 6 hrs

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2
Q

How to reduce contrast rxn in patient with contrast allery?

A

50mg prednisone 13 7 and 1 hr prior to contrast

50mg diphenhydramine 1 hr prior to dye

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3
Q

Benefit of fenoldopam?

A

selective dopamine agonist thought to reduce incidence of acute post op renal failure in pt undergoing major vascular surgery and/or recieving contrast dye.

systemic vasodilation in dose dependnt manner (unlike dopamine) while preserving/augmenting renal blood flow.

rapid onset, fast metabolism, good drug for treating severe blood pressure in pts w renal impairement

Don’t admin unless also attempting to reduce blood pressure

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4
Q

CI to extracorporeal shock wave therapy

A

pregnancy

bleeding diathesis

urinary obstruction below stone

UTI

relative: obesity, aortic aneusrym, orthopedic device, pacemaker

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5
Q

issues with dorsal lithotomy position for turp

A

-elevated preload

elevate intrabominal pressure and impaire resp fxn

LE nerve injury

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6
Q

How to deal with post op acute renal failure

A
  • Post renal: Check foley for obstruction
  • Pre-renal causes: hypovolemia (fluids), hypotension (vasopressors), CHF (inotropes/diuretics)
  • Intrinsic: consult nephrologist, consider dialysis if necessary, usually self limited 7-14 days
  • Limit any further injury: no contrast, NSAIDs, nephrotoxic agents
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7
Q

Issues with water bath for lithotripsy? General issues

A

submerged in warm water–>vasodilation–>hypotension

water hydrostatic pressure –>HTN (blood redistributes to central circ), and reduction FRC

arrythmias

alveolar rupture w hemoptysis

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8
Q

How to limit dysarrthmias with lithotripsy

A

stop procedure

check direction of shock wave

check timing on EKG (R wave)

reduce energy of shock if possible

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9
Q

Why creatinine a good measure of GFR

What does BUN:CR ratio> 10:1 indicate

A

secreted and not reabs by kidney. takes days to demonstrate acute decline in GFR, confounded by diuretics

usually produced by conditions of decreased tubular flow (hypovolemia, CHF, cirrhosis)

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10
Q

Level of spinal needed for lithotripsy?

A

T6-Renal is T10-L2 (excessive diaphragm movemement can interfere w procedure

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11
Q

diuretics

A
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12
Q

head to toe Chronic renal failure concerns

A

neuro: urremic encephalopathy, peripheral/autonomic neuropathy,
cards: accelerated CAD, fluid overload, CHF, HTN, pericarditis, arrythmias, autonomic neuropathy, conduction blockade
resp: pulm edema, pleural effusion

GI: delayed gastric empyting; bleeding,

endocrine:

  • hyper: K, mAg, Po4, uric acid
    hypo: na ca, hypoalbumin,

met acidosis

heme: anemia (low EPO), plt and WBC dysfunction

endocrine; insulin resistance, 2 hyperparathyroidism , high TG

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13
Q

RBF autoregulation

What reduces GFR

A

80-180

NE, Epi, Angiotensin 2, symathetic activation

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14
Q

drugs affected by chronic renal failure

A

decreased protein binding–>enhanced drug effect: barbs and benzo, etomidate:

active metabolites dependent on renal excretion: keta,ine, morphine, meperidine,

increased BBB permeability and uremic toxins, effects anesthetics may be enhanced

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15
Q

How to view hyperkalemia and case canceing

A
  1. severity and chronicity
  2. need to proceed w surgery: avoid factors that would further hyperK-hypovent, acidosis, succ, K containing fluids
  3. 5 reasonable
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16
Q

etiology of anemia

How is renal failure anemia compensated for etiology

How can plt dysfunction be treated

A

decreased EPO, GI bleeding, vit def,

right shift oxy hemoglobin dissociation curve & increased 2,3 DPG

DDAVP desmopressin–>release factor 8 and WVF

17
Q

How does chronic renal failure affect my intraoperative course

A
  • eval volume status: hypervolemic bf dialsysis and hypo after. consider invasive monitors dependning on severity of coexisting dz and surgery
  • consider rapid seq due to delayed gastric emptying
  • avoid drugs heavily dependent on renal elim. cisatra vs roc balanced technique with fent midaz and inhalat first choice.
  • if pt at risk for additonal renal damage, ensure adequate hydration and perfusion
  • avoid hypervent (shift hemoglobin oxygen curve to left, and hypoventiation (hyper)
18
Q

How to perserve renal fxn in ARF

A
  • prevention bc mortality as high as 50%
  • ensure adequate hydration
  • avoid nephrotoxic agents: aminoglycosides, contrast, NSAIDS,
  • consider renal; protective agents
19
Q

protential but unproven renal protective agents

A

dopamine- D1 D2 agonist-renal vasodilation

fenoldopam-D1 agonist -vasodilation, increase RBF and GFR, naturesis and diuresis

mannitol: osmotic diuresis, may relieve tubular obstruction caused by sloughed off endothelail cells, free radical scavanger
furosemide: causes diuresis NAK2CCL), may reduce demand by blocking resportion

N acetylcysteine: antioxidant-protect againist contrast dye nephropahy

ANP: synethetic ANP-increases GFR

20
Q

How to eval causes of acute renal failure

A
  • postrenal: eval foley consider irrigating
  • pre-renal: look for signs of hypovolemia/hypotension increased renal vascular resistance, fluid bolus if can tolerate fluid otherwise diuretic/inotrope, consider lasix to wash out slouh off epithelail cells that could cause obstruction
  • renal: ischemia, nephrotoxins, intrinisc dz, ATN (FENA>2
21
Q

How to assess volume status in RF

A

Dialysis: last dialysis, compare weights,

vitals, UOP, CXR

signs hypervolemia: HTN, pulm edema, peripheral edema, JVD

signs hypovolemia: hypotension, tachycardia, orthostasis, dry mucous membranes

22
Q

how to manage fluids during transplant?

concern with blood transfusion in pt with transplanted kidney. how blood should be processed before transfusion.

A

important to maintain adequare intravascular volume and mainatin renal blood flow to reduce post op ATN and promote early onset graft fxn: isotonic fluids 3:1 ratio

If blood necssary admin washed/leukoreduced, irradaiated (reduce risk transfusion graft vs host, CMV neg pack red blood cells

exposure to leukocyte antigens in blood may lead to development of alloantibodies predisposing to rejection

23
Q

meds given during kidney transplant

A

heparin before clamping to prevent clotting

manniol and lasix to promote diuresis and in case mannitol free radical scavanger

24
Q

How to treat hyperkalemia.

EKG signs

A

peaked T widened QRS, prolonged PR)

-get code cart and treat according to ACLS

calcium: cardiac membrane stabilize immediate effect

shift extracellular K into cell: insulin/glucose (10-20min), B2 agonist (albuterol), sodium bicarb (less acidosis), hyperventilate (alkalosis)

25
Q

Why CRF pts a risk for bleeding

A

heparin used during dialsysis, plt dysfxn

26
Q

When would you cancel a case for hyponatremia? At what level is it dangerous why?

A
  • Urgency surgery
  • Lab value, Baseline, chronic or acute
  • Signs sx of hyponatremia
    • Neuro: fatigue, lethargy, H/A, confusion, irritable, restlessness, AMS
    • Cardiac: cardiopulm arrest
    • GI: N/V
  • Cerebral edema, seizure, coma, brain stem herniation (brain swelling <130
27
Q

What is HRS

A

Life threatnning renal failure that develops in ESLD and ascites with eleavted creatinine >1.5. characterized by vasoconstriction of renal vasculature, decreased GFR, preserved tubular fxn, hyperosmolar urine, urine sodium <10, azotemia, normal renal histology

28
Q

diagnosising HRS?

A

renal fxn that improved w fluid challeneg of 1.5l Albumin likely pre renal

urinary sodium>10 meq granular casts ATN

Major

  1. advanced liver dz and portal HTN
  2. low GRF (serum creatine >1.5 creatinine clearance <40
  3. absence of shock, infection, fluid loses, tx w nephrotoxic agents
  4. no improvement in renal fxn to a 1.5 L fluid challange
  5. absence of proteinuria, <500mg/day urinary obstruction, renal paranechymal dz
    minor: oliguria <500ml/24 hr, low urine sodium <10 mEq, urine osm>serm osm, spotaneous dilutional hyponatremia (sodium <130), absence RBC in urine
29
Q

pathophysiology HRS

types

tx

A

-endothelail (NO and prostcyclin), glucagon -increased levels of vasodilators lead to splanic vasodilatin–>reduced effective volume sensed by kidney–>RAAS + sympathetic NS, –>persistant vasodilation splanchnic circc and reduced perfusion of kidney results in profound intrarenal arterial vasoconstriction –>HRS

HRS 1- rapidly progressive creatinine >2.5 cc <20ml/in in less than 2 weeks

HRS 2: creatinine >1.5

medical tx: albumin (volume expansion), midodrine (vasoconstritor), octreotide (inhibitor splanchic vasodilation), transplant

30
Q

How does pneumoperitoneum cause oliguria

A
  1. decreased CO–>increased secretion ADH
  2. sympathetic induced release of catecholamines–>avtivate RASS
  3. release of inflammatory mediators can result in AKI
31
Q

concerns about bicarb admin

A
  • generation of Co2which can diffuse into cells worsening intracellular acidosis
  • L ward shift of oxyhemoblobin diss curve increasing hemoglobins affinity for oxygen and decreased unloading
  • hyperosmolar state 2/2 to excessive sodium
  • hypokalemia 2/2 movement K from extracellular to intracellular space
32
Q

post op polyuria

tx DI

A

DI: hypoosmolar fluid-l

mobilization of third space fluid

diuretics

osmotic diuresis from hyperglycemia

tx:

ow sodium-1/2 NS or D5W (DDAVP)-hyperatremia

DDAVP

D5-1/2NS at normal maintenance rate plus 2/3 of prev hours UOP. Do not replace full uop, and monitor for hyperglycemia. If fluid requirements exceed 350-400ml/hr consider giving DDAVP.

33
Q

drugs to avoid inRF

A

morphine, ketamine, meperidine (cerebral irritants)

decrease dose of benzo 2/2 exaggerated drug effect

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