Renal Flashcards

Question

Enflurane use in renal dysfunction?

Answer 1

* Decreased RBF, GFR, and UOP r/t decrease in BP * 2-5% metabolized with metabolites renally excreted * Fluoride ions * Renal failure following enflurane has been reported * Genetics? * Alkaline degradation products conjugated to **thiol products**

Answer 2

* Decreases RBF, GFR, and UOP * Metabolized to trifluoroacetic acid * Prolonged sedation \> 24 hours have fluoride ions 15-50 umol/L * *although serum fluoride levels may rise, nephrotoxicity extremely unlikely, even in the presence of enzyme inducers* * *prolonged sedation (\>24 hours at 0.1-0.6% iso) of critically ill patients has resulted in elevated plasma fluoride levels, without evidence of kidney impairment* * *up to 20 MAC hours of isoflurane may lead to fluroide levels \>50, without detestable postop kidney dysfunction* * No renal impairment

Answer 3

* Decreases RBF, GFR, and UOP * Minimal metabolism * No evidence of nephrotoxic effects * No renal impairment

Answer 4

* 3-5% biodegradation * Inorganic fluoride ions * Fl ions the same or higher than enflurane * Can be \> 50 μmol/L * *not associated with clinically significant renal dysfunction* * Increased NAG (β – N – acetylglucosaminidase) * Intracellular indicator of acute proximal renal tubular injury * BUN and plasma creatinine did not change * CO2 absorbers with potassium or sodium hydroxide * Base-catalyzed degradation * Vinyl ether compound called Compound A * Renal PCT injury in rats * *increased compound A with increased respiratory gas temperature, low flow anesthesia, dry barium hydroxide absorbent (baralyme)* * Barium hydroxide \> soda lime * *alkali such as barium hydroxide lime or soda lime (but not calcium hydroxide) can degrade sevo* * No renal failure noted in low flow or closed- circuit anesthesia

Answer 5

* Renal metabolism makes significant contributions morphine metabolism * No difference in clearance rates even in patients with cirrhosis * 1-2% unchanged in urine * About **90% excreted by kidneys** with the rest via biliary excretion * Accumulation of metabolites may occur in patients with renal failure * M6G (active/75-85%) and M3G (inactive/5-10%) * Prolonged respiratory depression \> 7 days reported * *Single-dose studies of morphine in renal failure demonstrate no alteration in disposition. Chronic administration may result in accumulation of metabolites which have potent analgesic and sedative effects* * *decrease in PB of morphine in ESRD which mandates reduction in initial dose*

Answer 6

* Hepatic metabolism to normeperidine * *neurotoxic, renally excreted metabolite* * *not recommended for use in pt with poor renal function* * Normeperidine produces CNS stimulation and toxicity can manifest as myoclonus and seizures * Urinary excretion is principal elimination route * Is pH dependent * Acidification of urine may speed elimination * ½ life is about **15 hours; up to 35 hours** in patients with renal failure * In patients receiving meperidine for \> 3 days – delirium maybe observed * Especially in the elderly

Answer 7

* Hydromorphone is metabolized to hydromorphone-3-glucuronide, which is excreted by the kidneys. * active metabolite accumulates in patients with renal failure and may cause cognitive dysfunction and myoclonus. * Codeine also has the potential for causing prolonged narcosis in patients with renal failure and cannot be recommended for long-term use.

Answer 8

* Metabolized to norfentanyl (minimally active) * \<10% excreted unchanged in urine * Detected for 72 hours * Prolonged respiratory depression in chronic renal failure patients * appears to be a better choice of opioid for use in ESRD because of its * lack of active metabolites, * unchanged free fraction, and * short redistribution phase. * Small-to-moderate doses, titrated to effect, are well tolerated by uremic patients.

Answer 9

* \< 1% unchanged * N-dealkylation metabolites are considered active (10%) * Maximal renal tubular reabsorption of free drug * Due to high lipid solubility * Metabolites excreted equally between renal/biliary * Increased plasma concentrations and prolonged respiratory depression has been noted in chronic renal failure patients * *pharmacokinetics are variable, and has been reported to cause prolonged narcosis*

Answer 10

* Elimination ½ time and plasma clearance not altered * Protein binding is reduced and free drug increases * \< 1% decreased unchanged * *caution in adminsitering a loading dose, but total dose and infusion dose similar to those patients with normal renal function*

Answer 11

* With renal failure * No changes in PK and PD * In patients on hemodialysis * Reduced clearance and prolonged elimination ½ life * Lower infusion rate required * *remifentanil rapidly metabolized by blood and tissue esterases to a weak active (about 4,600 times less potent), mu opioid agonist compound that is renally excreted, remifentanil acid.* * *clearance of remifentanil acid can be reduced in renal failure, but clinical implications of metabolite are limited*

Answer 12

* Hepatic metabolite – hydromorphone 3-gluconoride (Inactive) * Potential to accumulate with renal failure – neurotoxic * \< 1% free hydromorphone excreted in urine * Caution in renal failure patients

Answer 13

* Metabolite pyrrolidine (inactive) * 20-50% excreted as methadone * 10-45% in feces * Safe to use

Answer 14

* Metabolites noroxycodone (inactive) and oxymorphone (active) * Prolonged from 2.3 hours to 3.9 hours in patients with renal failure * Reduce dose and increase interval

Answer 15

* Metabolized to hydromorphone * Hydromorphone 3 glucuronide (neurotoxic) * Decreased clearance in patients with renal disease * Reduce dose and increase interval

Answer 16

* Hyperkalemia * 0.5 -1 mEq/dl increase in potassium * *potassium rise is generally well tolerated in patients with chronically elevated serum potassium levels* * *want K \<5.5 if considering succinylcholine admin* * Renal failure patients are no more susceptible to exaggerated response to succinylcholine than normal patients * Infusions problematic * Succinylmonocholine- *weakly active metabolite that is excreted by kidney* * Weaker neuromuscular blocker with longer duration of action * *Conflicting reports of plasma cholinesterase activity in renal failure*

Answer 17

* Metabolized by butyrylcholinesterase (aka pseudocholinesterase) * *decreased pseudocholinesterase activity in renal failure which can cause slower recovery from bolus dose of mivacurium in anpehric patients* * Longer duration of action and slower rate of recover in patients with CKD * Decreased amount of butyrylcholinesterase and accumulation of active metabolites * Induction dose OK * DOA maybe increase by 10 – 15 minutes

Answer 18

* Hofmann elimination and ester hydrolysis * OK in renal failure patients * Laudanosine metabolite (30% renal) * Plasma ½ life same in both normal and renal failure patients * *may cause seizures in experimental animals and can accumulate with repeated dosing or continuous infusion* * *however, not been realized in ICU patients with renal failure receiving prolonged infusions*

Answer 19

* Hofmann elimination (77% of elimination) * OK in renal failure patient * 16% renally eliminated * 4-5x’s as potent as atracurium so less laudanosine metabolites

Answer 20

* Long- acting neuromuscular blocking drug * *metabolized by liver into less active intermediates, the elimination half life still primarily dependent on renal excretion (60-80%)* * *NM function should be closely monitored if these agents are used in patients with abnormal renal function* * 40-60% cleared through the kidneys * Avoid * Metabolites are less potent and renally excreted

Answer 21

* Metabolized in liver to 3 different metabolites * 3-OH vecuronium has 80% potency of vecuronium * *can accumulate in anephric patients receiving continuous infusion* * Approximately 30 - 40% excreted unchanged by the kidney * Single dose fine, but multiple doses/infusions may require adjustment * *DOA of vec prolonged as result of reduced plasma clearance and increased elimination half life* * *incubating dose lasts 50% longer in patients with ESRD*

Answer 22

* Primarily eliminated by the liver and excreted in the bile * NO active metabolites * Approximately 30% excreted unchanged by the kidney * Single dose fine, but multiple doses/infusions may require adjustment * *conflicting results*

Answer 23

* Neostigmine, pyridostigmine, physostigmine, & edrophonium * Renal excretion accounts for 50 – 75% of the drugs * Renal failure decreases plasma clearance as much, if not more than, the long- acting neuromuscular blocking drugs * *prolonged duration of action in ESRD due to heavy reliance on renal excretion* * *anticholinergic agent atropine and glyco, used in conjunction with anticholinesterases, are similarly excreted by kidney* * *no dose alternation of anticholinesterase is required when antagnoizing NMB in patients with reduced renal function*

Answer 24

* 75% of dose is eliminated through the urine * Clearance approaches GFR * With substantial renal impairment, clearance of sugammadex/rocuronium complex was decreased and elimination ½ life was increased * *reversal of NMB by sugammadex is still as timely and effective in these patients as in healthy controls* * Dialysis is inconstant in removing suggammadex * **Do not use if creatinine clearance \< 30 ml/hr**

Answer 25

* Characterized by: * Deterioration of renal function- hours to days * Failure to excrete waste products * Failure to maintain fluid & electrolyte homeostasis * Occurs: * All hospitalized - 5% * Critically ill – 8 - 10% * Postoperative AKI * General – 1% * Cardiothoracic & vascular - 30% * The causes of AKI are classically divided into * prerenal,- *results from hemodynamic or endocrine factors that impair renal perfusion* * intrarenal (or intrinsic), and * postrenal- *from urinary tract obstruction* * Preoperative AKI increases: * hospitalization, * mortality, and * morbidity

Answer 26

* Classifications: * RIFLE criteria (Risk- Injury-Failure-Loss-End-Stage) * Acute Kidney Injury Network * Kidney Disease: Improving Global Outcomes (KDIGO) * *combines both RIFLE and AKIN criteria* * Based on * Increase of serum creatinine of 0.3 mg/dL over 48 hours * Increase of serum creatinine \> 50% over 7 days * Acute drop of UOP to \< 0.5 mL/kg/hr for \> 6 hours * Anuria \< 100 ml/day – sign of severe injury * *Increased appreciation for AKI since development of KDIGO criteria.* * *Even mild changes in kidney function seem to be associated with short and longterm adverse outcomes*

Answer 27

* Prerenal- hypoperfusion * *from stoelting 22.4* * *hemorrhage* * *GI fluid loss* * *trauma* * *surgery* * *burn* * *cardiogenic shock* * *sepsis* * *hepatic failure* * *aortic/renal artery clamping* * *thromboembolism* * Intrarenal (intrinsic)- underlying renal causes, ischemia, nephrotoxins * *ATN most common @75%* * *ischemia, nephrotoxic drugs, solvent,s heavy metals, contrast dye* * *acute glomerulonephritis* * *vasculitis* * *interstitial nephritis* * Postrenal- urinary collecting system obstruction * *nephrolithisasis* * *BPH* * *Clot retention* * *bladder carcinoma*

Answer 28

Risk Factors for Perioperative Renal Failure (Stoelting’s 22.6) * Pre-existing renal dx * Advanced age * CHF * PVD * DM * Emergency surgery * Major surgery (aortic aneurysm repair) * *cardiac, vascular, major abdominal surgery at increased risk for renal dysfuntion* Iatrogenic Risk Factors * Inadequate fluid replacement * Hypotension * Delayed treatment of sepsis * Nephrotoxic drugs

Answer 29

**Neurologic**: * confusion, * asterixis, * somnolence, * seizures, * polyneuropathy r/t build up of protein & amino acids * autonomic and peripheral neuropathies **Cardio**: * systemic HTN, * *RAAS activation lead to* HTN * CHF, * *increased cardiac demand r/t anemia and HTN makes CKD patients prone to congestive heart failure* * pulmonary edema r/t sodium & water retention; * *increased permeability of alveolar-capillary membrane predispose to pulmonary edema* * dysrhythmias, * *due to deposition of Ca in conduction system* * uremic pericarditis * *may present with CP, cardiac tamponade or may be asymptomatic* * *accelerated CAD and PVD* * ***CO _increases_** in kidney failure to **maintain oxygen delivery** due to decreased blood-oxygen carrying capacity*

Answer 30

* anemia * *Almost always present when CrCl \<30 mL/min* * *Generally 6-8 g/dL due to decreased erythropoietin* * *difficult to maintain \>9 even with transfusions* * coagulopathy * HCT 20-30% common d/t hemodilution & decreased erythropoietin * increased risk of bleeding d/t uremia-induced platelet dysfunction * *decreased Plt Factor III as well as decreased PLT adhesiveness and aggregation* * *wbc function impaired* * *susceptible to infections*

Answer 31

* metabolic acidosis * *failure to excrete nonvolatile acids produce increased anion gap metabolic acidosis* * hyperkalemia * *potentially lethal consequence* * *occurs in pt with CrCl \<5 mL/min but also develops rapidly in patients with higher clearances in setting of large potassium loads (trauma, hemolysis, infection, K administration)* * hyperphosphatemia * hypocalcemia * *r/t resistance of PTH* * *decreased intestinal absorption Ca and hyperphosphatemia-associated calcium deposition into bone* * *symptoms hypocalcemia rarely develop unless pt is alkalotic* * hypoalbuminemia * *d/t anorexia, protein restriction, dialysis* * hypermagnesemia * *usually mild* * hyperuricemia * Hyponatremia * d/t water and sodium retnetion

Answer 32

* anorexia * N & V * ileus * gastroparesis * *secondary to kidney-disease associated autnomic neuropathy may predispose to perioperative aspiration* * GI bleeding * *hypersecretion gastric acid leads to peptic ulceration and GI hemorrhage in 10-30% patients* * increased incidence hep B and C- associated with hepatic dysfunction

Answer 33

* respiratory & urinary tracts and sites where breaks in normal anatomic barriers have occurred * impaired immune response- white cell function are impaired in patients with kidney failure * *LEADING CAUSE OF MORBIDITY AND MORTALITY IN PATIENTS WITH AKI*

Answer 34

* No specific treatment modalities * *ONLY lifesaving surgeries should be undertaken in pt with AKI* **Treatment aims:** 1. Limit further renal injury 2. Correct fluid/ electrolyte/ acid-base derangements 3. Reverse underlying causes of injury (hypovolemia, hypotension, low CO, sepsis) 4. Maintain MAP 65 or \> (no evidence supporting outcomes with supraphysiologic values) 5. Fluid resuscitation(goal-directed therapy) & vasopressor therapy (norepi/vasopressin) 6. Diuretics not advised * *attempting to convert oliguric to non-oliguric AKI by using diuretics may increase mortality risk and permeennt risk injjury* 7. Alkalinization of urine with sodium bicarb. (rhabdo); reduces incidence of contrast-induced nephropathy 8. Dialysis- mainstay for severe AKI. complete day of surgery/ day before Indicated with: 1. volume overload 2. hyperkalemia 3. severe metabolic acidosis 4. symptomatic uremia 5. overdose with dialyzable drug

Answer 35

* Poor – mortality \> 20% * If dialysis required \> 50% Those who die from AKI usually die of failure of other organ systems after prolonged and complex hospital courses * 15% will fully recover * 5% will have renal insufficiency and remain stable * 5% will experience continued renal function deterioration

Answer 36

* ensure adequate organ perfusion and oxidation during anesthesia is key principle * fluid, blood products, vasopressors, and inotrops are tools to achieve adequate organ perfusion * *MAP \<60 for 11-20 min or \<55 for \>10 minutes is associated with increased incidence AKI. Avoid hypotension during anesthesia and treat promptly* * KDIGO guidelines propose to implement bundle of preventative measures for patients at high risk AKI: * maintain volume status and perfusion pressure * monitor Cr and urine output * discontinue nephrotoxic agents * use of alternative to radio contrast agent * maintain normoglycemia * functional hemodynamic monitoring * High risk patients should be identified preop * fluid losses and hypovolemia should b corrected by IV fluids * periop ADH and RAAS secretion minimized with adequate hydration before anesthetic induction * Oliguria signals inadequate systemic perfusion, * prevention of ARF requires rapid recognition through adequate monitors * if renal with questionable cardiac/pulmonary function- may need an arterial line for BP monitoring or CVP/Swan monitoring when appropriate * Avoid nephrotoxic drugs * NSAID * vanc * aminoglycosides * diuretics * contrast

Answer 37

* correction of hypovolema * h2 blocker, PPI, reglan for aspiration preventions * May need intraarterial BP for frequent blood draws, CVP

Answer 38

* Induction: * RSI with reduced dosages of induction drugs * Succinylcholine if K+ known * Maintenance: * Volatile anesthetics vs. TIVA * Controlled ventilation * Avoid hypoxia and hypercarbia which can result in reduced renal blood flow * *acidosis also can increase K*

Answer 39

* **Kidney damage (GFR \< 60 mL/min) for 3 or more months** * *slow, progressive, irreversible condition characterized by diminished functioning of nephrons and a decrease in renal blood flow, GFR, tubular function, and reabsorptive capacity* * **DM and HTN most common cause** (*account 2/3 of all cases of CKD)* * other causes: * glomerulonephritis, pyelonephritis, congenital defects * Multiple different stages of CKD * **GFR \< 25 mL/min require dialysis** or transplant * Ethnic variations * African American, Native American, & Hispanics have higher rates

Answer 40

* Stages 1. decreased renal reserve 2. renal insufficiency 3. end-stage renal failure or uremia * as number of functioning nephrons decrease, s/s and biochemical abnormalities become more severe * Intrarenal hemodynamic changes are likely responsible for progression of renal disease * Glomerular HTN * Glomerular hyperfiltration & permeability changes * Glomerulosclerosis

Answer 41

Reduce systemic & glomerular HTN: * ACE inhibitors * ARBs * Moderate protein restriction * *in animal models, protein intake can influence progression of renal disease* * *recommended for all renal failure patients to decrease protein* * Strict control of BG * *control BG can delay onset of proteinuria and slow progression nephropathy, neuropathy, and retinopathy* * Hyperlipidemia - statin therapy advised * *hyperlipidemia may accelerate renal diesease* * Smoking cessation * *linked to increased risk of development of kidney disease*

Answer 42

* Adaption: Large Renal reserve; patients w/ CKD remain relatively asymptomatic until RF is \< 10% of normal * Stage 1 * Decrease of \> 50% GFR * Changes in excretion of creatinine and urea (*as GFR decreases, these substances rise)* * Stage 2 * GFR – 10% of normal * Changes in solutes such as **potassium** * *****serum K concentrations maintained WNL until GFR approaches 10% of normal, then hyperkalmeia manifests* * Stage 3 * Variable * Changes in sodium homeostasis and regulation of ECF * *sodium balance usually remains intact despite progressive deterioration in renal function and variation dietary intake* * *system can become overwhelmed by abrupt increases in sodium intake, which results in volume overload. OR decreased sodium intake, resulting in volum depletion*

Answer 43

1. **Uremic syndrome-** *constellation of s/s that reflect kidney's progressive inability to perform excretory, secretory and regulatory functions. D/t failure of kidney to excrete number of uremic toxins* * anorexia * nausea * vomiting * pruritus * anemia * fatigue * coagulopathy 2. **Renal osteodystrophy-** *change in bone structure and minerlization with progressive CKD* * ***secondary hyperparathyroidism** and **decreased Vit D p**roduction by kidneys* * *impaired intestinal absorption **Ca*** * *hypocalcemia stimulates PTH secretion, which leads to bone resorption to restor Ca concentration* * *as GFR decreases, **decrease** in **phosphate** clearance **increases phosphate** in **body**, thereby also **decreasing Ca** concentration* 3. **Anemia** * *normochromic and normocytic anemia* * *causes fatigue, weakness, decreased exercise tolerance* * *excess PTH hormone also causes bone marrow to become fibrotic, also contributing to anemia* 4. **Uremic bleeding** * *increased tendency to bleed despite normal PLT, PT, PTT* * *Bleeding time is screening test that best correlates with tendency to bleed* * *hemorrhagic episodes sig source morbidity in pt with CKD* 5. **Neurological changes** * *initially mild symptoms (impaired abstract thinking, insomnia, irritability) progressing to sig changes (sz, obtundation, uremic encephalopathy, coma)* * *adv renal failure a/w distal symmetric mixed motor and sensory polyneuropathy marked by paresthesia and hyperesthesia of LE* 6. **Cardiovascular changes** * *Systemic HTN is most sig risk factor CKD. Increases r/f CHF, CAD, CVA* * *Silent MI, cardiac tamponade and uremic pericarditis (inflammation of visercal and parietal layer of pericardium by accumulation of metabolic toxins)* 7. **Altered protein binding of drug**s * Acidic drugs: less binding (benzos= increased FF)

Answer 44

1. Treat underlying cause 2. BP control * *BP can cause and be a consequence of CKD.* * *Multimodal drug therapy necessary* * *ACE or ARBs are first-line therapy in pt with proteinuria since both these drugs have shown to slow the rate of CKD progression* * *DIuretics, CCB, and aldosterone antagonists are other agents utilized* 3. **Adequate nutrition and protein restriction-** *reduce progression renal dx* 4. **Treat anemia** * ***desmopressin** can treat uremic bleeding* * ***conjugated estrogen**s improve bleeding time* * *treated with **erythropoietin** or darbepoetin* * *blood transfusions avoided d/t concern for antigen matching with transplant* * *iron injection to maximize response to erythropoietin* 5. **RRT***- no specific GFR however if GFR \<10, usually dialysis is required* * Hemodialysis * Peritoneal dialysis

Answer 45

Preoperative evaluation: * **Goal**: Preserve renal function and prevent kidney injury * **Renal function** – is a continuum: trends in lab values more important * **Stop nephrotoxic drugs:** (NSAIDS/aminoglycosides/contrast agents) * **Volume status** – dry and wet weights * **Drug administration**: bolus vs. infusion (based on estimated Vd) * **Labs**: * K \< 5.5 on DOS * H/H: 10/30 * Coags: DDAVP may be required * **HTN therapy** – well controlled; ACE/ARB therapy (hold?) * **DM management** – Target glucose 110 – 150 mg/dL * **G**I: Prophylaxis- all drugs renally secreted

Answer 46

**Monitors** * Minor/moderate: noninvasive monitors OK **(not on fistula arm)** * Complex (Advanced disease): A-line/CVP/PICCO/TTE or TEE * Where to place? * **Avoid radial/ulnar/brachial/axillary/** * Use dorsalis pedis or femoral * *TEE can be used for hemodynamic status* **Lines** * **Peripheral** * **Lower arm of dominant hand** * *avoid any venipuncture in nondominanrt arm as well as upper part of dominant arm.* * *any arterial line placed in arm with AV fistula will be inaccurate with BP and ABGs.* * Can dialysis catheter be used for anesthesia? * Yes, but highly discouraged and proper care is important * REmember 1) catheter must be accessed aseptically, 2) heparin must be aspirated and then 3) reinstalled after use. * **Central** * Maybe difficult to place * *esp with pt with tunnleed venous access or temp dialysis catheter.* * *can develop vein stenosis*

Answer 47

* Specific agent not as important as prevention of severe hypotension * Multiple causes * May be severe * *Variability in response to induction meds d/t changes in VD, protein binding, low pH, dependence on renal excretion for parent drug/metabolite* * **Treatment** * Replace volume before induction * Small doses or brief infusion of phenylephrine or norepinephrine OK * *may need additional hemodynamic monitoring to tightly control hypotension as well as hypertension* * *autoregulation altered in patients with chronic HTN* * *exaggerated CNS effects of anesthetic induction agents may reflect uremia-induced disruption of BBB* * *Attenuated SNS activity impairs compensatory peripheral vasoconstriction* * *small decreases in BV, use of PPV, abrupt changes in position, or drug induced myocardial depression can result in an exaggerated decrease in systemic BP* * RSI * Can use succinylcholine if K+ \< 5.5 mg/dL and necessary * No exaggerated release of K+ in CKD patients

Answer 48

* Balanced technique * Combination of volatiles, opioids, and muscle relaxants * *Sevo may be avoided but no evidence of patients having increased renal dysfunction after sevo.* * **Maintain MAP \> 65 mmHg** (\>75 mmHg with chronic HTN) * Norepinephrine or phenylephrine * Risk increases with MAP \< 60 mmHg for 20 min or \< 50 mmHg for 10 min * Check positioning frequently * *prone to bruising and sloughing* * *extra padding needed to protect vulnerable nerves around joints* * *BP cannot be taken on side with fistula* * *avoid having the arm with fistula tucked, so it may be assessed during the procedure* * Fluid management * Use 500 ml bag with 60 gtt tubing * NS vs ½ NS vs LR vs Plasmalyte * *LR generally avoided d/t K* * *0.9% NS may also cause hyperchloremic acidosis and renal vasoconstriction when used in large amounts* * 5% albumin OK * Blood products for those that require increased oxygen carrying capacity * UOP * **At least 0.5 cc/kg/hr** * Decrease most likely d/t low volume * *hypovolemia can increase renin, aldosterone and ADH levels which leads to a further decline in UOP* * *Preoperative hydration may be beneficial for those pt with severe renal dysfunction not requiring dialysis and those at high risk of postop renal failure.* * *500 cc crystaolloid should increase UOP in presence of hypovolemia* * Use of diuretics or vasodilators (fenoldepam) is controversial * *use of diuretics to prevent AKI not recommneded except for mgmt of severe fluid overload*

Answer 49

* Skeletal muscle weakness: from residual neuromuscular blockade or… antibiotics, acidosis, electrolyte imbalance * *Although residual NMB after reversal nondepol. NMB with anticholinesterase is rare, dx should b considered in patients with SKD who manifest signs skeletal muscle weakness during early postop period* * *other explanations (Abx, electrolyte imbalance) should also be considered when muscle weakness persists* * Caution w/ parenteral opioids – respiratory depression * ***exaggerated CNS depression** and **hypoventilation** with even **small** doses* * *select opioids **without** active **metabolites** that **do not rely** on **kidneys*** * Avoid NSAIDs * *N**SAIDs best avoided.** may also exacerbate HTN, precipitate edema and increase r/f CV complications* * Continuous ECG monitoring * *monitor for hyperkalemia* * Supplemental O2 * Check electrolytes, BUN, creatinine, HCT * Bleeding- uremic coagulopathy

Answer 50

* **Neuraxial** * Coagulopathy and peripheral neuropathy is a concern * Evaluate coagulation panel * Monitor closely * Maintain MAP * T4-10 level may improve renal function * *By decreasing catecholamine-induced renal vasoconstriction and supressing surgical stress response* * *PLT dysfunction and effect of residual heparin in pt receiving Hemodialysis must also be considered* * *adequate intravascular fluid volume must be maintained to minimize hypotension* * **Regional anesthesia- brachial plexus** * Document peripheral neuropathies prior to placement * presence of **uremic neuropatheis** should be evaluated before induction of regional anesthesia * Improved surgical conditions * Maximum vasodilation (greater blood flow), abolish vasospasm * *RA increases arterial blood flow and venous diameter during operation and early post op, preventing early thrombosis and associated fistula failure* * *associated risks include infection, neuropathy, PTX, and intravascular inje*ctio * ***duration** of **brachial** plexus **block** may be **shortened by 40%** in pt with chronic renal failure* * *not confirmed in controlled studies* * *co-existing metabolic acidosis may decrease threshold for sz in response to LA*

Answer 51

* Therapy for fluid overload- salt and water restrictions/ diuretic therapy? * *fluid overload due to a variety of conditions (CHF, RF, Hepatic cirrhosis) may be first recognized during preop assessment* * *may require elective sx to be delayed to reduce operative risk* * *first line therapy is restriction Na/H2O but diuretic therapy often indicated* * Grouped according to site and MOA * Proximal tubule diuretics * Osmotic diuretics * Loop diuretics * Distal convoluted tubule diuretics * Distal acting diuretics * Dopaminergic agonists * Na+/K+- ATPase pump – primarily responsible for Na+ out in exchange for K+ * *under normal conditions, \>1% of Na enters urine* * *Na/K ATPase pump causes net movement of positive charge out of cell, creating electrochemical gradient that causes Na to enter luminal (urine) side of cell* * Renal tubular cells allow Na+ influx

Answer 52

Proximal convoluted tubule ex- acetazolamide * Carbonic anhydrase inhibitors are drugs that inhibit carbonic anhydrase * net effect of these agents is of Na and HCO3, which would otherwise have been reabsorbed, remain in urine and results in alkaline diuresis * patient may develop metabolic acidsois when taking these * compensatory process in tubules accommodate effects of carbonic anhydrase inhibitors, so their long-term use rarely causes a problem * useful agents in contraction alkalosis from aggressive diuresis with loop diuretics * Can reduce CO2 and improve PaO2 with little accompanying change in pH * **_Uses_**: * morning sickness * open-angle glaucoma * increase respiratory drive in patients with central sleep apnea

Answer 53

Proximal convoluted tubule ex mannitol * mannitol is freely filtered at glomerulus, but poorly reabsorbed by renal tubule * causes osmotic diuresis * water-permeable segments of proximal tubule and loop of henle, fluid reabsorption occurs and filtered mannitol is concentrated * eventually, oncotic pressure in tubular fluid resists further fluid reabsorption * mannitol draws water from cells into plasma and increases RBF * USES: * Increase ICP * AKI prophylaxis in kidney transplantation * *no evidence to support mannitol is effective for prevention or treatment of AKI nepropathy outside of kidney transplant* * *SE*** * hypochloremia * intracellular increase K and H * circulatory overload with hemodilution and pulmonary edema * hyperkalemic metabolic acidosis * CNS depression * severe hyponatremia requiring hemodialysis

Answer 54

work on thick ascending limb of Henle loop * Ex- furosemide, bumetanide, torsemide * inhibits electroneutral transporter, preventing salt reabsorption from occurring * allow large salt load to pass to distal convoluted tubule * first line therapy for treatment of acute decompensated CHF

Answer 55

* ex- thiazides (HCTZ) and metolazone * MOA- Block NaCl cotransport mechnism across apical plasma membranes * distal tubule is relatively water impermeable, net NaCl absorption causes urinary dilution * Uses * HTN * Volume overload disorders * relieve symptoms of edema in pregnancy * A/E * electrolyte disturbance * volume depletion * pancreatitis * jaundice * diarrhea * aplastic anemia

Answer 56

* K-sparing diuretics and competitive aldosterone antagonists * Ex- spironolactone, eplerenone * usually, mineralocorticoid hormone, aldosterone, is released by body in response to angiotensin II or hyperkalemia * aldosterone stimulates Na reabsortpiona nd K excretion in collecting duct * inhibition of aldosterone causes mild natriuresis and K retention * Use * primarily for K sparing diuresis (in pt with volume overload receiving digitalis or hypokalemic alkalosis) * treatment of secondary hyperaldosteronism * ie cirrhosis, ascites

Answer 57

* Dopamine 1-3 mcg/kg/min is natriuretic owing primarily to a modest increase in GFR and reduction in Na reabsorption mediated by dopamine type 1 receptors * higher doses, pressor response to dopamine is beneficial in pt with **hypotension**, but little to **no renal effect in critically ill or septic patients** * **"renal dose"**: dopamine for treatment of AKI has not been demonstrated to have sig renoprotective properties and may * worsen splanchnic oxygenation, * impair GI function, * impair endocrine and immune function, * blunt ventilatory drive, and * increase risk of postcardiac sx afib * Fenoldopam is selective Da1 agonist with little cardiac stimulation

Answer 58

Urethroscopy: inspection of urethra Cystoscopy: inspection of the bladder Ureteroscopy: inspection of ureter Nephroscopy: inspection of intrarenal collecting system

Answer 59

* Age: All ages * Male:Female: 1:1 * **Incidence: 30 -40%** of all urological procedures * Etiology: * Hematuria, * tumors (bladder/ureteral), * stones, * strictures * Associated conditions: * Prostatic hypertrophy, * cystitis, * cancer, * hemorrhagic cystitis, * kidney stones, * uretero-pelvic junction obstruction

Answer 60

* **Position**: Lithotomy * Contractures may make difficult * Unique Consideration: Use of x-ray, fluoroscopy, or lasers * Placement of catheters, stents, or drains * **Antibiotics**: Cefazolin, Gentamicin (allergies?) * **Surgical** time: 15- 45 minutes * **EBL**: none * **Mortality**: \< 1% * **Morbidity**: infection, perforation, retained stones, & nerve injury

Answer 61

* Tumors: * Older patients with many different pre-existing conditions * CAD, CHF, PVD, COPD, and renal impairment * Nephrolithiasis: * Paraplegics and quadriplegics have predilection for stones * Repeat procedures * Contractions & pressure sores may make positioning difficult

Answer 62

* Topical * 2% lidocaine jelly with sedation * Regional * May require a **T8** level for procedures involving the **ureters** * Does **not abolish obturator** reflex (external rotation and adduction of thigh) * Spinal vs epidural (takes time to set up vs more stable cardiac profile) * *typically these procedures are outpatient and anesthetic should be planned accordingly* * *sacral block required for urethral procedures T9-T10 for procedures with bladder and T8 if involving ureter* ## Footnote *Anesthetic choice depends on type and length of procedure. age, coexisting dx, and patient preference*

Answer 63

* **Monitors**: Standardized * **Positioning**: Lithotomy * **Induction**: Standard * ETT vs. LMA * Succinylcholine?-- consider paraplegia/quadriplegia comorbidity * **Maintenance**: * Volatile vs. TIVA * Muscle relaxation not essential * Long- acting narcotics not necessary- *pretty minimal pain, tylenol, oxycodone sufficient* * **EBL**: minimal * **Emergence**: * No specific considerations

Answer 64

Complications * Decrease BP when lowering legs * Peroneal nerve injury * Pain * Is Toradol acceptable?- *generally always ask surgeon* * Bladder perforation * Shoulder pain, sudden hypotension and tachycardia * *hard to discern under general anesthesia* * Autonomic hyperreflexia * Spinal cord injury **above T6** * Sever HTN, bradycardia, dysrhythmias, and cardiac arrest * **TX**: * Deepen level of anesthesia * Labetalol 5-10 mg IV * SNP 0.5 – 5 mcg/kg/min * Phentolamine 2-5 mg IV

Answer 65

* Peroneal injury * Bladder perforation * Fever/ bacteremia * Pain is usually mild

Answer 66

Extracorporeal shock wave lithotripsy * *Treatment for disintegration of renal stones in non-lower pole of kidney and upper part ureter* * *in symptomatic pt with stone burden \<20 mm, ESWL is effective treatment, but a/w higher likelihood of repeat procedures* * *successful treatment depends on :* * *obesity* * *skin-to-stone distance* * *collecting system anatomy* * *stone compostiion* * *stone density/attenuation* * Shock waves focused at calculi in kidney or upper 2/3 of the ureter * Change in tissue density from body to stone cause a shearing/tearing effect * 10 – 20 mm stones or impacted stones * 1st Generation * High energy unit * Patient was immersed in water bath * Could result in significant CV nad Resp effects * Painful * 2nd and 3rd Generation * Low energy unit * *efficiency decreased, results in higher retreatment rates* * Uses small water filling coupling device or pad * Tightly focused sound beam * 28% still report severe pain

Answer 67

* Position: * 1st Generation: Placed into chair – then into water bath * 2nd/3rd Generation: Supine * Unique Consideration: Movement; Special table; shock waves * First Generation: ECG must be good quality – R wave used to trigger shock * May use atropine/glycopyrrolate to increase HR * Supraventricular complexes

Answer 68

Preoperative: * 1st Generation: placed in chair and lowered into a water bath * CV and Resp changes * 2nd/3rd : minimal hemodynamic changes Absolute Contraindication * Pregnancy * bleeding disorders * active UTI Relative * Presence of abdominal aortic aneurysm or orthopedic prosthetic device * Patients w/ pacemaker (place in non-demand mode) * Patients w/ AICD (turn off/on immediately before & after procedure) * Shock synchronized to 20 mms after R wave (absolute refractory period) * Shock waves can (rare) damage the device * Have alternative pacing device available

Answer 69

* Typically for pediatric, extremely anxious, & bilateral procedures * Does not decrease number of shock * **Induction**: Standard based on preop findings; LMA vs. ET * **Monitors**: Standard * **Maintenance**: Light GA +/- muscle relaxant * HFJV has been used to limit movement * **Fluids**: liberal use of fluids * Surgeon may request Lasix * **Emergence**: No special considerations

Answer 70

**_T6 level required_** * 1st generation * **Epidural** most common (unknown duration of surgery) * Use **saline** (air can dissipate shock waves and damage tissue) * **Do not use foam tape** (dissipate shock wave energy) * Spinal * Less control * 2nd/3rd generation * Spinal (opioids only: 50 mcg sufentanil) * Flank analgesia – EMLA cream (2.5% lidocaine/prilocaine) * Dermal analgesia – Prilocaine injection * Monitored anesthesia care

Answer 71

Multiple different combinations have been used * Propofol-fentanyl * Post op respiratory complications noted * Propofol-remifentanil * Bolus vs. PCA * Lack of post procedure pain control * Midazolam/ketamine

Answer 72

* Obstruction * Cardiac arrythmias * *Dysrhythmia may occur in 20-59% patient with piezoelectric source of shock waves versus 1.4-9% using electromagnetic lithotripers* * *dysrhythmic episodes do not appear to have any clinical significance* * *may be due to mechanical stress on conduction system from shock waves.* * *artifact and dysrhythmia common generally stops when lithotripsy is stopped* * Bleeding * *hematuria always present at end of procedure from shock wave induced endothelial injury to kidney and ureter* * *adequate hydration necessary to prevent clot retention* * Skin bruising * Damage to hollow organs * Especially the lungs * Flank pain * *painful hematoma may occur*

Answer 73

Transurethral resection of prostate * “Gold standard” therapy for BPH * *mainstay to alleviate urinary obstructive symptoms r/t BPH* * *BPH describes smooth muscle and epithelial cell proliferation within transition zone of prostate* * *symptoms of BPH reflect bladder outlet obstruction (static) and increased smooth muscle tone (dynamic)* * Can be done as outpatient procedure * **Several techniques:** * M-TURP or B-TURP * *use electrically powered cutting-coagulating metal loop* * HoLEP * Bipolar plasma vaporization or laser-vaporization * Aquablation * *minimally invasive water ablation technique, combines image guidance and robotics with high-velocity saline stream for targeted and heat-free removal of prostate tissue* * *Advantages: shorter surgery time, minimal to no blood loss and reduced risk of fluid absorption* * Anesthetic implications – comorbidities, anesthetic technique, LOS, patient/surgeon preference

Answer 74

* 40- 90 yr, typically 70s and 80s * 90% develop BPH; 20% of these need surgical intervention * Associated conditions: * COPD * Heart disease * DM * DIC (prostate CA)

Answer 75

* One of the most common urological operations * Completed with a resectoscope – monopolar& bipolar w/ continuous irrigant * *resection performed with continuous irrigation with isotonic solution* * *bleeding vessels coagulated with coagulating current* * *foley placed at end* * Operative time \< 2 hours-- *if greater, can cause excessive absorption of irrigating fluid which can cause:* * Dilutional Hyponatremia * Confusion * Seizures * Heart failure * *This is less of an issue with **continuous flow biploar resectoscope** where **saline** is used as **irrigant*** * KTP laser is now most common approach * Can be completed on anticoagulated patients & patients with bleeding disorders * Must wear protective eyewear * *minimally invasive technique that allows deep vaporization of prostate tissue with minimal blood loss*

Answer 76

* **Position**: Lithotomy or steep trendelenburg * **Special Instrumentation:** cystoscope, resectoscope, catheters, electrocautery * **Unique considerations**: Immobility is a must * *must be absolutely still because any movement can lead to perforation or injury to external sphincter, which can result in postop incontinence* * **Antibiotics**: Cefazolin and/ or Gentamicin 80 mg IV (allergies?) * **Surgical time:** \< 2 hours * **EBL**: 500 ml’s (3-5 ml’s/min of resection) * **Postop**: Irrigation of Foley to clear; Serum Na+ concentration * **Morbidity**: Bleeding (10%), absorption of irrigation fluid (2-5%), perforation (0.5%) * **Pain**: 1-3

Answer 77

* Patients are generally elderly with co-morbid conditions * *may have CAD, CHF, PVD, CVA, COPD, Renal impairment* * Resp: COPD common * *smoking hx, PFT, CXR, ABG* * CV: CAD/HTN common * *EKG* * *Assess exercised tolerance* * Neuro: Cerebrovascular disease; Alzheimer’s Disease * *assess mental status* * Renal: Renal impairment secondary to obstruction * *BUN, Cr, electolytes* * Endocrine: DM * *check BG* * Heme: if gland \> 80 grams need **T&C** * Preop tests & labs based off H & P

Answer 78

* Anesthetic technique: GA vs neuraxial * *regional allows eval for TURP syndrome* * Neuraxial anesthesia * Require **_T8 - 10 level_** * **__***T10 provides adequate regional anesthesia for TURP by achieving block that interrupts sensory transmission from prostate and bladder neck* * *in addition, this level eliminates uncomfortable sensation of bladder distention* * Potential for **earlier detection** o**f TURP syndrome** * Incidence of postdural puncture headache is very low * Spinal placement maybe difficult r/t arthritis

Answer 79

* **Induction**: Standard * **Maintenance**: Balanced (volatile/nitrous/opioids) * Muscle relaxation is not mandatory * Minimal to moderate blood loss (if venous sinuses entered) * Difficult to detect with irrigation fluid * **Emergence**: Minimal pain; changes in BP with lowering legs * Airway edema with steep Trendelenburg * **Complications** (intra/post-op): * Hypothermia, * *body temp decreases 1 degree C per hour of surgery* * *shivering occurs in 16% of pt who receive room-temp irrigation fluids* * *hypothermia does not develop if irrigation solution warmed to body temp* * bladder perforation, * *2% TURP procedures resulting in extraperitoneal fluid extravasation* * *awake pt with neuraxial anesthetic may complain during sx of new-onset pain localized to lower and and back* * *evidence of perforation usually not clear until postop* * TURP syndrome, * blood loss, or * *blood loss 2-4 mL/min but individual bleeding difficult to assess owing to mixing with irrigating fluid* * *serial assessment of Hgb may be necessary with prolonged procedures* * vision problems, * fever/bacteremia/sepsis

Answer 80

* Continuous irrigation fluid- visibility and waste removal (blood/tissue) * *surgoen needs clear view in order to perform procedure* * **Incidence**: 0.78 – 1.4% with 25% mortality for severe symptoms * **Time frame: _15 minutes_** (start of case) to **_24 hours_** postop * Resection of prostate opens large venous sinuses and large amounts of irrigation fluid can be absorbed * **10-30 ml’s** / **minute** * 6-8 L in cases that last 2 hours * Can decrease serum sodium **5-8 mEq/L** * **_Keep fluid height \<60 cm above bed heigh_**t * (Stoelting’s **\< 40** & Apex **\<30** beginning and **\< 15 end)** * Various types of fluid used * Based on type of equipment used * 1.2 – 1.5% glycine or sorbitol/mannitol **(monopolar cautery)** * Physiological saline (**bipolar** or **lasers**) * TURP syndrome refers to cluster of symptoms r/t hypervolemic water intoxication * 1) excessive volume expansion (respiratory distress, CHF, pulmonary edema, HTN, bradycardia, HoTN) * 2) Hyponatremia * mental confusion * nausea * Factors that predict increased irrigation fluid absorption during TURP 1. number and size of open venous sinuses * greater blood loss implies greater potential for irrigant absorption 2. surgical disruption of prostatic capsule 3. longer duration of resection 4. higher hydrostatic pressure of irrigating fluid 5. lower venous pressure at irrigant-blood interface

Answer 81

Fluid overload – HTN/bradycardia/pulmonary edema * Water toxicity (hypo-osmolality) - confusion/restlessness/seizures/lethargy * "**Classic triad"** noticed in awake patient * increase in systolic and diastolic pressures, and pulse pressure * bradycardia * mental status changes * **Hyponatremia**: * **\<120 mEq/L:** restlessness and confusion * **\< 115 mEq/L:** somnolence, nausea, decease cardiac contractility, hypotension, Wide QRS, ST elevation and dysrhythmias * **\< 100 mEq/L:** Seizures/coma, dysrhythmias, severe hypotension, and pulmonary edema * **Glycine toxicity -** N&V/HA/transient blindness/loss of light reflex * **Ammonia toxicity-** (conversion from glycine) N&V * **Hemolysis** – Anemia/clammy skin/hyperkalemia * Coagulopathy – Severe bleeding/DIC (\<1%) * **Systemic fibrinolysis** - * Prostate releases plasminogen activator – plasmin * Absorption of thromboplastin *Early manifestations TURP related to rapid intravascular volume expansion independent of change in serum osmolality and sodium* * *initial HTN and bradycardia from acute overload may evolve into LHF, pulmonary edema and cv collapse* * *with continued absorption, cerebral edema is consequence of hyponatremia* * *rapid change is responsible fo rmost s/s of TURP syndrome*

Answer 82

* **Terminate surgery as soon as possible** * Fluid overload * Ensure adequate oxygenation, ventilation, and circulation * **Monitoring**, fluid restriction, **furosemide 20 mg IV** * **Evaluate**: Chemistry, CBC, glucose, ABG, and obtain 12 lead EKG * **Goal**: \> 120 mEq/ * **Na \< 100 mEq/L = 3% NS @ \< 100 ml/hr** * *traditional rate of sodium correction of 0.5mEq/L/hr is for CHRONIC hyponatremia, not TURP syndrome* * *need hypertonic saline for TURP until Na \>120* * *treatment with hypertonic saline is a/w development of **demyelinating central nervous lesions (central pontine myelinolysis**) d/t rapid increase plasma osmolality* * *hypertonic saline reserved for pt with severe hyponatremia* * *demyelinating syndomre occurs because of excessive shrinkage of brain cells after rapid hydration with hyperosmolar solution* * *brian cells have extruded important osmoles to compensate for chronic hypotonicity* * ***no** reports of **demyelination** **after** **treatment** of **acute** **TURP** syndrome* * For **seizures**: midazolam * **Chest x-ray** for pulmonary edema * **DIC** * Blood products as required * CV Collapse * ACLS

Answer 83

* Complete resection of the prostate – typically for adenocarcinoma * *nonmalignant disease of prostate is usually treated by TURP* * **Radical**: entire prostate, both seminal vesicles and lymph nodes * Despite being limited to men: 2nd most common cancer * 99% \> 50 years old * African American 50% \> Caucasian men * Treatment * Radiation * hormonal, cryo, chemo, internal and external radiation therapy * High focused ultrasound * Watch and wait- *low risk groups* * *identified by tumor aggressiveness and biomarkers* * Surgical approach * Typically in younger men * *elderly patients who may die from other disorders other than prostate Ca are being more frequently advsed to pursue nonsurgical therapy* * *surgical approach may be endoscopic with or without robotic assistance* * *one concept is emerging that prostate Ca may exist in both clinically significant and insignificant forms*

Answer 84

* Age: 40 -80 yr * Incidence: 20% will develop BPH; 9% will develop prostate CA * Etiology: Aging * Associated conditions: COPD, CAD, HTN, DM & RF

Answer 85

* **Position**: Lithotomy; steep Trendelenburg (robotic) * **Incision**: low midline; multiple port sites (robotic) * **Unique Considerations:** Da Vinci robot system; abdominal insufflation, possible sural nerve graft * **Surgical time:** 2-4 hours (experienced surgeon) * **EBL**: 500 to 1500 ml’s (less w/ robot) * **Postop care**: Catheter care & pain control * **Morbidity**: Bleeding, DVT, Infection, PE, impotence, & infection * **Pain**: 6-8

Answer 86

* Typically, elderly men with multiple pre-existing medical conditions * Respiratory: PFTs, CXR, AGB * Cardiovascular: ECG, stents?, exercise tolerance * Neurologic: increased ICP and increased ocular pressure- neurosurgical consult if intracranial lesion or VP shunts * Renal: pneumoperitoneum decreases RBF and oliguria * Musculoskeletal: arthritis * Endocrine: blood sugars * Hematologic: T&C 2-4 units * Preop evaluation should be directed toward detection and optimization of conditions prior to surgery * **Bowel prep** may lead to **dehydration** * Moderate blood loss expected: * \< 30 g – no T/C necessary * 30 – 80 g – T/C 2 units * \> 80 g – T/C 4 units

Answer 87

* Regional Technique (spinal/ continuous spinal/ continuous epidural) +/- sedation **(open procedure only)** * May reduce blood loss and postoperative complications * **T8- T10 level**- depending on incision site * Sedation – deep to maintain comfort * Propofol * Dexmedetomidine * Benadryl

Answer 88

* General Anesthesia (laparoscopic/robotic/open) +/- epidural * **Induction**: Standard based on patient conditions * *establish lines prior to patient positioning* * *intraarterial/CVP not routine but may be indicated based on comorbidities* * **Monitoring**: Standard (a-line & central line based on patient conditions) * **Maintenance**: Balanced (volatile/opioid/neuromuscular blocking) * **_Pt movement is not tolerated with robotic procedures_** * Indigo carmine to visualize ureter- *possibility of reaction* * *refrain from dosing epidural catheters because meds will move cephalad during procedure* * **Blood/Fluids:** Moderate to large blood loss; large bore IV’s; T/C as needed; goal-directed fluid management * May need vasopressors * **Emergence**: steep trendelenburg- *may contribute to airway edema* * **Complications**: indigo carmine reaction, hemorrhage, hypothermia, VAE, & robot malfunction

Answer 89

* will be placed in steep trendelenberg (30-45 degrees head down) * facilitates pelvic access in lap and robotic prostatectomy * **prevent sliding-** patient must be well situated on OR table, within vacuum bean bag and then firmly secured with belt * **arms placed on angled armboards** prior to lower end table during lithotomy position to minimize crushed fingers * arms tucked at side * pressure points padded carefully * additional padding to distribute pressure from shoulder braces, if in use * pay attention to r**adial (At humeru**s), **ulnar (at elbow**) and **lateral femoral cutaneous (lithotomy leg holders**) to minimize axonal injuries * **oral ulceration and conjunctival burns may occur d/t lithotomy related reflux of gastric contents** * preop antacid * stomach drainage by OG tube * waterproof eye tape

Answer 90

* Hemorrhage * Airway edema * DVT * Hypothermia * Peroneal nerve injury * Pain- * Maybe severe * ERAS protocols- *epidural, TAP blocks*

Answer 91

* Main indication: Renal cell carcinoma – 85 – 90% of solid renal masses * Men 2x’s \> women * **"triad" S/S** * hematuria * flank pain * palpable mass * *sometimes tumors are discovered d/t vena caval involvement* * *s/s dilated abdominal veins, variocele, lower extremity edema, pulmonary embolism.* * *a/w more advanced dx and a/w mets and poor prognosis.* * *Cell cancers of upper urothelial tract (ureters, renal pelvis) also treated by radical nephrectomy* * *Nephrectomies fall into 3 groups: simple, partial and radical* * Refractory to chemotherapy and radiation * *surgical resection only cure* * Up to 25% of patients, the tumor extends into the renal vein and inferior vena cava * More common in right sided renal cell carcinoma * Can have severe pulmonary congestion * High incidence of thrombus

Answer 92

* **Position**: Varies based on surgeon preference, disease stage & location- supine or flank * **Incision**: Flank, thoraco-abdominal, or trans-abdominal * *incision may cause PTX* * **Unique considerations:** Renal artery/vein or IVC involvement. Very large tumors may require CV surgeon and cardiac bypass * **Time**: 3- 4 hours * **EBL**: 500 – massive * **Morbidity**: Prolonged ileus, pneumothorax, vascular injury * **Pain**: 8 – 10 (radical) 4 (laparoscopic)

Answer 93

* May be of any age * Elderly with multiple pre-existing medical conditions * Preop evaluation should be directed toward detection and optimization of conditions prior to surgery * **Respiratory**: Increased post-op pulmonary complications because of location of incision (nonlaparoscopic) * If pulm dx- consider post-op respiratory complications * **Hematologic**: polycythemia has been associated with renal cell carcinoma * Assessment of functional capacity is important * Those with cavo-atrial disease may require PFT’s and TTE/TEE to look for thrombus * **Some may develop paraneoplastic syndrome** * **Hypercalcemia**, eosinophilia, increased prolactin, & erythrocytosis * sig injuries can also occur to colon, duodenum, and liver

Answer 94

* General Anesthesia (laparoscopic/robotic/open) * **Regional** – Epidural vs TAPS/paravertebral block * Avoided in those with cavo-atrial involvement * **Induction**: Standard based on patient conditions * **Monitoring**: Standard, a-line & central line (left sided - before SVC) * Intra-op TEE (*if tumor involvement with atria)* * **Maintenance**: Balanced (volatile/opioid/neuromuscular blocking) * **Positioning**: lateral/Trendelenburg * Decreased FRC, increased V/Q mismatch, & atelectasis * **Blood/Fluids:** Moderate to large blood loss; **large bore IV’s;** T/C; goal-directed fluid management * **Complications** (intra/post-op): * pneumothorax, * hypotension w/ positioning, * indigo carmine, * methylene blue, * post-nephrectomy syndrome, * brachial plexus injury

Answer 95

* Hemorrhage * Thrombus * Hypothermia * Pain * Maybe severe * ERAS protocols