Renal Assessment Flashcards
When and How should we ask pts about kidney disease?
- During the Pre-op interview
- Have you ever had any kidney problems?
- Have you ever had any changes in bladder function in the last year?
- Have you ever had any kidney stones?
- Have you ever had kidney failure, dialysis, or two or more kidney infections?
pts answer answer yes to having If kidney problems what should you ask about next?
- What is your kidney problem?
- Do you make urine?
- Are you on dialysis?
If they answer yes to dialysis what do you need to ask/ do?
- Ask what kind of dialysis (Hemodialysis, Peritoneal)
- When was the last time you had dialysis?
- What was your last potassium? 4.
What should you always document if a patient undergoes dialysis?
POTASSIUM! Pull it over in the chart and document that you have seen it!
What is the measurement for Chronic Kidney Disease? Chronic Renal Failure?
- CKD- GFR of less than 60 ml/min/1.73m2 for 3 months
- CRF- GFR less than 15 ml/min/1.73m2
Most common reasons we will see Chronic Renal Failure patients
AV fistula creation or revision
GI Bleeding
Tidbits about IV placement and solutions to use
- 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
Situations where dialysis will be required
- Oliguria
- Fluid Overload
- Hyperkalemia
- Severe Acidosis
- Metabolic Encephalopathy
- Pericarditis
- Coagulopathy
- Drug Toxicities
Before taking dialysis pts for surgery what should the patient look like?
- OPTIMIZED! –Surgery that day
- Review fluid removed
- Note post dialysis K+ (should be < 5.5)
- Pre/post dialysis weights
When should scheduled meds be administered? Why?
- 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
How can uremic encephalopathy present?
- Asterixis
- Myoclonus
- Lethargy
- Confusion
- Coma
- Seizures
Should we regularly administer regional anesthesia to these patients?
Avoid if possible, lower dose d/t peripheral neuropathy
Disequilibrium Syndrome
Dialysis Related –Transient CNS disturbance after rapid shifts in ECF and ICF
What would you assess for neurologically that could be associated with renal disease?
- Uremic Encephalopathy
- Autonomic Neuropathy
- Peripheral Neuropathy
- Dementia
- Disequilibrium Syndrome
Hematological assessment of the renal patient: What to look for and why
- Anemia (Hgb 6-8 g/dL)
- Decreased EPO production- (See Garmins Lecture)
- Decreased RBC production
- Bone Marrow Suppression (excess PTH)
- Impaired platelet function
- 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)
How do Renal patients tolerate anemia well?
- Increased 2.3 DPG (Right shift on oxydis curve)
- Metabolic Acidosis (Also R shift on oxydis curve)
Cardiac Assessment for renal pt: What will you look for?
- Increased CO (Compensate for low O2 capacity)
- HTN (RAAS activation)
- L Ventricular Hypertrophy
- CHF w/ Pulm Edema (after compensation reached)
- Deposits of Calcium (on heart valves and on conduction system
- Arrhythmias (Electrolyte imbalance)
- Uremic Pericarditis (Chest pain, tamponade)
- CAD, PVD (From triglycerides (osmotic from Liver))
Pulmonary Assessment of the Renal Patient: What to look for
- Increased MV (Compensate for Acidosis)
- “Butterfly Wings” on CXR (Pulm Edema)
Endocrine Assessment of the renal patient: What to look for
- Diabetic (Poor glucose tolerance)
- Hyperparathyroidism —-Prone to fractures from bone degredation
- High Triglycerides
- No degredation of hormones (increased amount in circulation)
GI/Liver Assessment of the Renal Patient: What to look for
- GI Hemmhorage
- N/V ——Hypersecretion of Gastric Acid–Possible RSI
- High Hep B and C Incidence
Renal Failure impact on drugs, and what to do about it
- Drug effects or pharmacokinetics altered d/t
- Anemia- (Decrease MAC of Volatile agents) —–No enflurane!!!
- Decreased total Protein (Decrease all protein bound drugs)
- Electrolyte Abnormalities
- Fluid Retention
- ANY drugs eliminated UNCHANGED by the kidneys are CONTRAINDICATED (Gallamine, Phenobarb, LMWH)
LMWH- unique consideration
Cleared by the kidney but NOT by dialysis == prolonged duration
Lab tests that could be useful
- CMP
- GFR
- CBC
- PT/INR
- ABG
Tests that could be useful and what are they looking for?
- CXR
* Uremic pneumonitits
* Pericardial Effusion
* Fluid Status
- CXR
- EKG
* Ischemia
* Conduction Blocks
* Left Vent Hypertrophy
- EKG
- Echo
* Hypertrophy
* EF
* Pericardial Fluid
- Echo
Why is BUN not reliable as a sole lab value? What value BUN is indicative of a low GFR
It can vary with protein dietary intake. >50 mg/dL is indicative in pts with normal diet
What is the most common cause of increased BUN?
CHF secondary to the reabsorption of BUN????? (I don’t know what this means)
Plasma Creatinine
- Source?
- Lag Time?
- Elderly Patients?
- 50% increase in plasma creatinine=
- Skeletal Muscle
- 8-17 hr lag time after a change in GFR
- Elderly pts Cr levels stay normal constantly —–If elevated, very indicative of renal failure
- Coresponding 50% decrease in GFR
Creatinine Clearance Values 1-6
- Normal 100-120 ml/min
- Decreased Renal Reserve 60-100 mls/min
- Mild Renal Impairment 40-60 mls/min
- Moderate Insufficiency 25-40 mls/min
- Renal Failure < 25 mls/min
- ESRD < 10 mls/min
Common renal pt lab abnormalities
- Hyponatremia
- Hyperkalemia
- Metabolic Acidosis (high anion gap)
- Hypermagnesemia
- Hypocalcemia (If pt hypotensive and not responsive to pressors, give Ca++)
- Hypoalbuminemia
- Hyperglycemia
3 treatments we use to lower K+
- Calcium Gluconate 10% (10-20ml)
- Sodium Bicarb (50-100 mEq/L)
- Glucose (50 ml of 50%) and Insulin (10 units regular)
Treatment for high K that shifts K+ into cells
Sodium Bicarb and Glucose/ Insulin
Treatment for high K+ that antagonizes the effects on cardiac muscle
Calcium Gluconate 10% (10-20 ml)
When would we transfuse renal failure patients?
Only when absolutely indicated < 6-7 g/dL or significant intra-op blood loss
What should we always have on every pt before performing regional anesthesia?
Coagulation Panel
Renal Failure and Coags
- Bleeding time increased despite normal PT/PTT
- Released defective von Willebrand Factor is the most important cause
What should we give if the patient has an increased bleeding time?
DDAVP- Desmopressin (0.3-0.4 mg/kg over 30 min) Cryoprecipitate (10 units IV over 30 min)
