Renal - Anesthesia

Question 1

Why are pts w renal dz more susceptible to barbiturates (brevital) and benzos?

Answer 1

decreased protein binding therefore more free drug available

Question 2

Which three anesthetic IV agents have no significant differences in uremic pts?

Answer 2

1. Propofol
2. Etomidate
3. Ketamine

Question 3

What is the major concern w diazepam (Valium) in a renal pt?

Answer 3

active metabolites can accumulate

Question 4

Which 2 opioids warrant caution in a renal pt? Why?

Answer 4

Morphine and meperidine (Demerol)

accumulation of metabolite can cause problems (resp depression and seizures, respectively)

Question 5

Although Atropine and glyco can be used safely in renal pts, what can occur w repeated dosing?

Answer 5

accumulation of metabolites

Question 6

What are the renal implications of Metoclopramide?

Answer 6

it is partly excreted unchanged by kidney but it can accumulate in renal failure

Generally save to use in single dose

Question 7

Sucs is safe in pts w K _______ mEq/L

Answer 7

<5.0 mEq/L

Question 8

What is the musc relaxant of choice in a renal pt? Why?

Answer 8

Cisatracurium

It is degenerated by Hoffman elimination

Question 9

NDNMBs to avoid in renal pts b/c they are primarily dependent on renal excretion

Answer 9

• Pancuronium
• Pipecuronium
• Alcuronium
• Doxacurium

Question 10

Where are Vec and Roc primarily eliminated>

Answer 10

Liver

Although there is some mild prolongation in RF pts

Question 11

How are NDNMB reversal agents affected by RF?

Answer 11

reversal agents are primarily excreted by the kidney but their half-lives are prolonged ~ as much as some of the NDNMBs so over all, there is usually not problem

Question 12

Surgery should be performed _______ hrs after last dialysis

Answer 12

6-8 hrs

Question 13

6 Factors to evaluate in a renal pt preoperatively

Answer 13

1. Last dialysis
2. Most recent K
3. Systemic effects of kidney dz
4. EKG
5. RBC transfusion for hgb <6-7
6. dialysis access site

Question 14

Intraoperative concerns on a renal pt

Answer 14

1. No BP cuff on fistula arm
2. Use invasive hemodynamic monitors
3. Avoid LR b/c of K
4. control ventilation to decrease risk of resp acidosis (on top of the metabolic acidosis they probably already have)

Question 15

Pts w which comorbidity (along w renal fail) have 10X the peri-op morbidity of pts w this comorbidity and no RF

Answer 15

DM

Question 16

Key factor in the causation of periop renal failure

Answer 16

Hypovolemia

Question 17

post-op renal failure has a mortality of ______

Answer 17

~50%

Question 18

T/F: it is easier to tx the complications of fluid overload than it is to tx ARF

Answer 18

True

Question 19

Should renal dose dopamine ever be used?

Answer 19

No. It may do more harm than good

Question 20

Risk factors for peri-op RF

Answer 20

• Sepsis
• Hypovolemia
• Obstructive jaundice
• Aminoglycoside antibiotics
• NSAIDS
• ACE inhibitors
• Recent dye injections

Question 21

Renal pts on ACE inhibitors can be resistant to _______ and _______ but respond well to _______

Answer 21

phenylephrine and ephedrine

vasopressin

Question 22

Mgmt for intra-op oliguria

Answer 22

1. Make sure foley is patent
2. Check fluid status/give bolus
3. Check CVP or PAC
4. Increase low BP
5. Give lasix if home med that wasn’t taken day of surgery
6. Consider mannitol