Renal Assessment

Question 1

When and How should we ask pts about kidney disease?

Answer 1

• During the Pre-op interview
  
  • 1. Have you ever had any kidney problems?
  • 2. Have you ever had any changes in bladder function in the last year?
  • 3. Have you ever had any kidney stones?
  • 4. Have you ever had kidney failure, dialysis, or two or more kidney infections?

Question 2

pts answer answer yes to having If kidney problems what should you ask about next?

Answer 2

• 1. What is your kidney problem?
• 2. Do you make urine?
• 3. Are you on dialysis?

Question 3

If they answer yes to dialysis what do you need to ask/ do?

Answer 3

1. Ask what kind of dialysis (Hemodialysis, Peritoneal)
2. When was the last time you had dialysis?
3. What was your last potassium? 4.

Question 4

What should you always document if a patient undergoes dialysis?

Answer 4

POTASSIUM! Pull it over in the chart and document that you have seen it!

Question 5

What is the measurement for Chronic Kidney Disease? Chronic Renal Failure?

Answer 5

• CKD- GFR of less than 60 ml/min/1.73m2 for 3 months
• CRF- GFR less than 15 ml/min/1.73m2

Question 6

Most common reasons we will see Chronic Renal Failure patients

Answer 6

AV fistula creation or revision

GI Bleeding

Question 7

Tidbits about IV placement and solutions to use

Answer 7

• No brachiocephalic veins! —- needed for fistula placement
• Do not place IV or BP cuff on operative side
• No LR (K+) or D5W
• 500 ml bag
• microgtt tubing

Question 8

Situations where dialysis will be required

Answer 8

• Oliguria
• Fluid Overload
• Hyperkalemia
• Severe Acidosis
• Metabolic Encephalopathy
• Pericarditis
• Coagulopathy
• Drug Toxicities

Question 9

Before taking dialysis pts for surgery what should the patient look like?

Answer 9

• OPTIMIZED! –Surgery that day
• Review fluid removed
• Note post dialysis K+ (should be < 5.5)
• Pre/post dialysis weights

Question 10

When should scheduled meds be administered? Why?

Answer 10

• After Dialysis
  
  • Dialysis removes many medications from the blood.
• Medications more likely to be removed if they are low-molecular weight, water soluble, and non protein bound

Question 11

How can uremic encephalopathy present?

Answer 11

1. Asterixis
2. Myoclonus
3. Lethargy
4. Confusion
5. Coma
6. Seizures

Question 12

Should we regularly administer regional anesthesia to these patients?

Answer 12

Avoid if possible, lower dose d/t peripheral neuropathy

Question 13

Disequilibrium Syndrome

Answer 13

Dialysis Related –Transient CNS disturbance after rapid shifts in ECF and ICF

Question 14

What would you assess for neurologically that could be associated with renal disease?

Answer 14

1. Uremic Encephalopathy
2. Autonomic Neuropathy
3. Peripheral Neuropathy
4. Dementia
5. Disequilibrium Syndrome

Question 15

Hematological assessment of the renal patient: What to look for and why

Answer 15

• Anemia (Hgb 6-8 g/dL)
• 1. Decreased EPO production- (See Garmins Lecture)
• 2. Decreased RBC production
• 3. Bone Marrow Suppression (excess PTH)
• 4. Impaired platelet function
• 5. Impaired WBC function
• Why do they tolerate this?
  
  • Increased 2.3 DPG (Right shift on oxydis curve)
  • Metabolic Acidosis (Also R shift on oxydis curve)

Question 16

How do Renal patients tolerate anemia well?

Answer 16

• Increased 2.3 DPG (Right shift on oxydis curve)
• Metabolic Acidosis (Also R shift on oxydis curve)

Question 17

Cardiac Assessment for renal pt: What will you look for?

Answer 17

1. Increased CO (Compensate for low O2 capacity)
2. HTN (RAAS activation)
3. L Ventricular Hypertrophy
4. CHF w/ Pulm Edema (after compensation reached)
5. Deposits of Calcium (on heart valves and on conduction system
6. Arrhythmias (Electrolyte imbalance)
7. Uremic Pericarditis (Chest pain, tamponade)
8. CAD, PVD (From triglycerides (osmotic from Liver))

Question 18

Pulmonary Assessment of the Renal Patient: What to look for

Answer 18

1. Increased MV (Compensate for Acidosis)
2. “Butterfly Wings” on CXR (Pulm Edema)

Question 19

Endocrine Assessment of the renal patient: What to look for

Answer 19

1. Diabetic (Poor glucose tolerance)
2. Hyperparathyroidism —-Prone to fractures from bone degredation
3. High Triglycerides
4. No degredation of hormones (increased amount in circulation)

Question 20

GI/Liver Assessment of the Renal Patient: What to look for

Answer 20

1. GI Hemmhorage
2. N/V ——Hypersecretion of Gastric Acid–Possible RSI
3. High Hep B and C Incidence

Question 21

Renal Failure impact on drugs, and what to do about it

Answer 21

• Drug effects or pharmacokinetics altered d/t
  
  • 1. Anemia- (Decrease MAC of Volatile agents) —–No enflurane!!!
  • 2. Decreased total Protein (Decrease all protein bound drugs)
  • 3. Electrolyte Abnormalities
  • 4. Fluid Retention
  • 5. ANY drugs eliminated UNCHANGED by the kidneys are CONTRAINDICATED (Gallamine, Phenobarb, LMWH)

Question 22

LMWH- unique consideration

Answer 22

Cleared by the kidney but NOT by dialysis == prolonged duration

Question 23

Lab tests that could be useful

Answer 23

1. CMP
2. GFR
3. CBC
4. PT/INR
5. ABG

Question 24

Tests that could be useful and what are they looking for?

Answer 24

• 1. CXR
     * Uremic pneumonitits
     * Pericardial Effusion
     * Fluid Status
• 2. EKG
     * Ischemia
     * Conduction Blocks
     * Left Vent Hypertrophy
• 3. Echo
     * Hypertrophy
     * EF
     * Pericardial Fluid

Question 25

Why is BUN not reliable as a sole lab value? What value BUN is indicative of a low GFR

Answer 25

It can vary with protein dietary intake. \>50 mg/dL is indicative in pts with normal diet

Question 26

What is the most common cause of increased BUN?

Answer 26

CHF secondary to the reabsorption of BUN????? (I don't know what this means)

Question 27

Plasma Creatinine 1. Source? 2. Lag Time? 3. Elderly Patients? 4. 50% increase in plasma creatinine=

Answer 27

1. Skeletal Muscle 2. 8-17 hr lag time after a change in GFR 3. Elderly pts Cr levels stay normal constantly -----If elevated, very indicative of renal failure 4. Coresponding 50% decrease in GFR

Question 28

Creatinine Clearance Values 1-6

Answer 28

1. Normal 100-120 ml/min 2. Decreased Renal Reserve 60-100 mls/min 3. Mild Renal Impairment 40-60 mls/min 4. Moderate Insufficiency 25-40 mls/min 5. Renal Failure \< 25 mls/min 6. ESRD \< 10 mls/min

Question 29

Common renal pt lab abnormalities

Answer 29

1. Hyponatremia 2. Hyperkalemia 3. Metabolic Acidosis (high anion gap) 4. Hypermagnesemia 5. Hypocalcemia (If pt hypotensive and not responsive to pressors, give Ca++) 6. Hypoalbuminemia 7. Hyperglycemia

Question 30

3 treatments we use to lower K+

Answer 30

1. Calcium Gluconate 10% (10-20ml) 2. Sodium Bicarb (50-100 mEq/L) 3. Glucose (50 ml of 50%) and Insulin (10 units regular)

Question 31

Treatment for high K that shifts K+ into cells

Answer 31

Sodium Bicarb and Glucose/ Insulin

Question 32

Treatment for high K+ that antagonizes the effects on cardiac muscle

Answer 32

Calcium Gluconate 10% (10-20 ml)

Question 33

When would we transfuse renal failure patients?

Answer 33

Only when absolutely indicated \< 6-7 g/dL or significant intra-op blood loss

Question 34

What should we always have on every pt before performing regional anesthesia?

Answer 34

Coagulation Panel

Question 35

Renal Failure and Coags

Answer 35

- Bleeding time increased despite normal PT/PTT - Released defective von Willebrand Factor is the most important cause

Question 36

What should we give if the patient has an increased bleeding time?

Answer 36

DDAVP- Desmopressin (0.3-0.4 mg/kg over 30 min) Cryoprecipitate (10 units IV over 30 min)