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NURA 606 Adv Health Assessment > Renal Assessment > Flashcards

Renal Assessment Flashcards

1
Q

Expected GFR for someone with Chronic Kidney Disease (CKD)

A

GFR < 60 ml/min/1.73 m2 for 3 months

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2
Q

Expected GFR for someone with Chronic Renal Failure (CRF)

A

15 ml/min/1.73m2

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3
Q

ESRD defined

A

loss of renal function for 3 months or more

DM accounts for half of cases & HTN for 1/4

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4
Q

Co-morbidities of renal dysfunction

A

CV disease
HTN
electrolyte issues

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5
Q

Perioperative considerations for the patient with ARF.

A

pts requiring surgery with ARF are VERY ILL.

don’t take these patients to the OR without careful consideraton

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6
Q

Dialysis will be required in the following situations:

A 
oliguria
fluid overload
hyperkalemia
severe acidosis
metabolic encephalopathy
pericarditis
coagulopathy
refractory GI symptoms
drug toxicity
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7
Q

Hemodialysis vascular access set up

A

AV fistula = cephalic vein anastomosed to radial artery

Jugular or femoral vein for emergency access

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8
Q

Pre operative dialysis assessment

A
  • optimization, optimization, optimization!
  • dialysis should occur day of surgery or day before surgery
  • review dialysis flowsheet if available
  • amount of fluid “taken off”
  • pre and post dialysis eights compare with the day of surgery wt
  • Note POST dialysis chemistry: serum K < 5.5 mEq/L

consider that these patient’s obviously just had fluid removed and you don’t want to fluid overload them in surgery, but their potential level of dehydration IMMEDIATELY post dialysis + vasodilation from VA may cause hypotension/hemodynamic instability and warrant some fluid

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9
Q

Which kinds of drugs will be removed by dialysis?

A

low molecular weight
water soluble
non protein bound

READILY CLEARED BY DIALYSIS, so some drugs may need to be administered POST dialysis so they are not removed during dialysis.

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10
Q

RF: neuro assessment

A 
UREMIC ENCEPHALOPATHY
-asterixis
-myoclonus
-lethargy
-confusion
-seizures
-coma
AUTONOMIC NEUROPATHYD - hemodynamic instability
PERIPHERAL NEUROPATHY - document pre op
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11
Q

What is disequilibrium syndrome? Anesthetic considerations?

A
  • can occur s/p dialysis
  • transient CNS disturbance after rapid decrease in ECF osmolarity compared with ICF osmolarity
  • dementia

If noted, may want to discuss pts status with surgical team and delay surgery if necessary

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12
Q

RF, hematological assessment: reasons for anemia

A

typical Hgb = 6-8 g/dL

  • decreased erythropoietin production
  • dec RBC production & cell life span
  • GI blood loss, hemodilution, bone marrow suppression
  • excess PTH replaces bone marrow with fibrous tissue
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13
Q

RF, hematological assessment: anemia compensation

A
  • *most patients tolerate the anemia well (except CAD)**
  • increased 2,3 DPG
  • metabolic acidosis also favors a rightward shift
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14
Q

RF, hematological assessment: other hematological considerations

A

Impaired platelets (qualitative)

  • dec plt factor III activity
  • dec adhesiveness & aggregation
  • possibly related to release of defective von Willebrand factor??*
  • –administration of DDAVP may be helpful in improving von willebrand factor

Impaired WBC function - INFECTIONS!!

dialysis = residual anticoagulation VS promotion of hypercoagulable state

hypocomplementemia with dialysis

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15
Q

Aseptic technique

A

INFECTION COMMON CAUSE OF DEATH! - over the top vigilant

care with ETT - prone to pulmonary infections

IVs, line insertion
try and preserve blood vessels on the NON DOMINANT ARM in case they may need an AV fistula on that arm eventual. So try and put IVs on the DOMINANT arm

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16
Q

RF: CV assessment

A
  • inc CO
  • –compensation for dec O2 carrying capacity
  • HTN - NA retention, renin angiotensin activation
  • LVH common
  • CHF with pulmonary edema after limits of compensation reached
  • Deposition of calcium
  • –in the conduction system & on the heart valves

-Arrhythmias - electrolyte imbalances

  • Uremic pericariditis
  • –can be asymptomatic, chest pain, tamponade, usually secondary to inadequate dialysis

-Accelerated CAD, PVD

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17
Q

RF: fluid balance assessment

A
  • fluid overload VS intravascular depletion s/p dialysis/aggressive diuretic therapy
  • body weight
  • VS (orthostatic hypotension & tachycardia)
  • atrial filling pressures

-mucous membranes; ask, “Do you get dizzy when you stand up?”

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18
Q

RF: pulmonary assessment

A
  • MV increased to compensate for metabolic acidosis
  • inc pulm extravascular water = interstitial edema = widened alveolar/arterial O2 gradient
  • “Butterfly wings” on CXR secondary to inc permeability of alveolar capillary membrane (edema even with normal pulmonary capillary pressure)

hyperventilation, interstitial edema, alveolar edema, pleural effusion

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19
Q

RF: endocrine assessment

A
  • peripheral resistance to insulin = poor glucose tolerance
  • hyperparathyroidism = prone to fractures
  • abnormal lipid metabolism = accelerated atherosclerosis
  • kidneys do not degrade hormones and proteins normally = inc circulating PTH, insulin, glucagon, GH, LH, PL
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20
Q

RF: GI/Liver Assessment

A
  • 10 - 30% of pts will develop GI hemorrhage
  • anorexia
  • N/V
  • hypersecretion of gastric acid + delayed gastric emptying (autonomic neuropathy)
  • high incidence of Hep B and C in these patients (multiple transfusions)
  • ascites with dialysis
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21
Q

RF, impact on drugs: effects altered due to…

A
  • anemia
  • dec serum protein (alters protein binding)
  • electrolyte abnormalities (can alter effect of drug, i.e. low Na can increase risk of Li toxicity, more prone to digoxin toxicity)
  • fluid retention (alters Vd of MR)
  • abnormal cell membrane activity (alters pharmacodynamics or receptor/drug level)
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22
Q

Drugs eliminated by kidneys unchanged are ________. Examples?

A

CONTRAINDICATED

Gallamine, phenobarbital, LMWH (metabolized or cleared by the kidneys and NOT removed by dialysis – RISK OF BLEEDING INCREASED EVEN FURTHER and PROLONGED DOA

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23
Q

Best MR to choose for a patient with RF. WHY?

A

atracurium or cisatracurium

not cleared by the kidneys!

24
Q

Things to consider when getting labs on any patient.

A
  • will this result change my anesthetic plan??
  • will the result come back in a short enough window to have a meaningful impact on my plan, if not, DON’T GET IT!

For example, (just because these patients are typically anemic) H&H may not necessarily be warranted on a short procedure with conscious sedation

Also, baseline K would be a good value to have in case you have to administer any drugs that would alter serum K levels (succ, lasix, etc. )

25
Q

The NORMAL chemistry panel

A 
Sodium (135-145 mEq/L)
Potassium (3.5-5.0 mEq/L)****
Chloride (95-105 mEq/L)
Sodium bicarb (venous - 19-25 mEq/L, arterial - 22-26 mEq/L)
Calcium (4.5-5.5 mEq/L)
Phosphate (2.4-4.7 mg/dL)
Magnesium (1.5-2.5 mEq/L)
Serum Osmolality (280-300 mOsm)
26
Q

GFR: purpose, values

A

indicative of NEPHRON function

  • BUN (10-20 mg/dL)
  • Plasma creatinine (0.7-1.5 mg/dL)
  • —GFR can decrease 50% w/o rise (Not accurate indicator especially in elderly)
  • creatine clearance (110-150 ml/min)
27
Q

Renal Tubular Function

A

Assesses concentrating ability of kidneys

  • urine specific gravity (1.003 - 1.030)
  • urine osmolarity (38-140 mOsm/L)
28
Q

BUN: normal value, value interpretation, pit falls

A
  • Normal: 10-20 mg/dL
  • varies inversely with GFR & directly with protein catabolism
  • > 50 mg/dl is indicative of a dec GFR (in patients with normal diets)
  • BUN is a NOT a sensitive index b/c urea clearance also depends on the production of urea
  • BUN can be abnormal despite a normal GFR due to: high protein diet, GI bleed, febrile illness
  • most common cause of in BUN is CHF secondary to the reabsorption of BUN
29
Q

Cr: normal value, value interpretation, pit falls

A
  • Plasma Cr is a specific indicator of GFR - freely filtered but not reabsorbed
  • 8 - 17 hour lag time after a change in GFR before the inc creatinine levels are seen
  • suggestive (but not indicative) of acute renal failure
  • usually a 50% inc in plasma cr reflects a corresponding dec in GFR
  • skeletal muscle = source of Cr
  • elderly patient - Cr levels stay normal constant due to :
  • –dec muscle mass and GFR
  • –If CR inc in the elderly, this may be indicative of renal failure
30
Q

Creatinine clearance: what is it?, how do you measure it?, values?

A
  • 24 hour collection most accurate although 2 hour tests also helpful
  • creatinine clearance approximates GFR
Normal: 100-120 ml/min
dec renal reserve: 60-100 ml/min
mild renal impairment: 40-60 ml/min
moderate insufficiency: 25-40 ml/min
renal failure: <25 ml/min
ESRD: <10 ml/min
31
Q

Lab/test abnormalities common with renal failure

A
  • assess the adequacy of dialysis
  • hyponatremia (hypernatremia rare)
  • HYPERKALEMIA (hypokalemia with dialysis)
  • metabolic acidosis with high anion gap
  • hypermagnesemia
  • hypocalcemia (unclear etiology)
  • hypoalbuminemia (esp with dialysis)
  • hyperglycemia (if insulin resistant)
32
Q

Hyperkalemia TX, calcium gluconate: dose, MOA, onset, duration, side effects

A 
Dose: calcium gluconate 10%, 10-20 ml IV
MOA: antagonizes effects on cardiac msucle
onset: immediate
duration: brief
SE: avoid with dig therapy
33
Q

Hyperkalemia TX, sodium bicarbonate: dose, MOA, onset, duration, side effects

A 
dose: sodium bicarbonate, 50-100 mEq IV
MOA: shift K into cells
onset: prompt
duration: short
SE: Na overload
34
Q

Hyperkalemia TX, glucose + insulin: dose, MOA, onset, duration, side effects

A 
dose: glucose, 50 ml of 50% soln + insulin, 10 units regular insulin
MOA: shift K into cells
onset: prompt
duration: 4-6 hours
SE: hyperglycemia, hypoglycemia
35
Q

Hyperkalemia TX, dialysis: MOA, onset, side effects

A

MOA: remove K from body
onset: immediate
SE: need vascular access

36
Q

Hyperkalemia TX, ion exchange resin: MOA, onset, side effects

A

MOA: remove K from body
onset: 1-2 hours
SE: Na overload

37
Q

The NORMAL CBC: RBC

A

male: 4.6-6.2 million/mm3
female: 4.2-5.4 million/mm3

38
Q

The NORMAL CBC: HGB

A

male: 13.5-18 g/dL
female: 12-16 g/dL

39
Q

The NORMAL CBC: HCT

A

male: 40-54%
female: 38-47%

40
Q

The NORMAL CBC: WBC

A

5000-10,000/mm3

remember - RF patients are at high risk for iatrogenic infections

41
Q

RF, Transfuse only when absolutely indicated: < ____ or ____________________.

A

< 6-7 g/dL
OR
significant intra operative blood loss

42
Q

What does a normal plt ct mean in a RF patient?

A

Does not mean much

RF patients may have an issue with platelet QUALITY, not count

43
Q

RF coagulation abnormalities: anesthesia considerations

A
  • If regional anesthesia is planned – need a coagulation panel!!!!
  • increased bleeding despite normal PT, PTT
  • bleeding time is BEST screening test

-Important cause of coagulation issue - RELEASE OF DEFECTIVE VON WILLEBRAND FACTOR
RX: desmopressin (0.3 - 0.4 mg/kg over 30 min); cryoprecipitate (10 units IV over 30 minutes)

44
Q

RF, labs and tests: pulmonary - chest xray

A

check for:

  • fluid status
  • –butterfly wings
  • determine presence of HTN related CV disease
  • pericardial effusion
  • uremic pneumonitis
  • enlarged heart
45
Q

RF, labs and tests: CV – EKG

A

check for:

  • hyperkalemia
  • —tall T waves, ST depression, widening QRS
  • hypokalemia
  • —peaked or flattened t waves, prolonged PR and QT
  • hypocalcemia
  • —prolonged QT
  • ischemia
  • conduction blocks
  • LVH
  • digitalis toxicity
  • —shortened QT interval, depressed ST
46
Q

RF, labs and tests: pulmonary - ABG

A

check for:

-hypoxia and acid/base status especially if dyspnea noted on exam

47
Q

RF, labs and tests: CV – ECHO

A

check for:

  • ventricular EF
  • hypertrophy
  • wall motion abnormalities
  • pericardial fluid
48
Q

Bleeding time: normal value, factors assessed

A

3 - 10 minutes

platelet function

49
Q

platelet count: normal value, factors assessed

A

150,000-400,000 cell/mm3

vascular integrity

50
Q

prothrombin time (PT): normal value, factors assessed

A

10-12 seconds

I, II, V, VII, X

51
Q

International Normalized Ration (INR): normal value, factors assessed

A

0.8-1.2

I, II, V, VII, X

52
Q

Plasma thromboplastin time (PTT): normal value, factors assessed

A

25-35 seconds

I, II, V, VIII, IX, X, XI, XII

53
Q

Activated clotting time (ACT): normal value, factors assessed

A

90-120 seconds

I, II, V, VIII, IX, X, XI, XII

54
Q

Thrombin time: normal value, factors assessed

A

9-11 seconds

I, II

55
Q

Fibrinogen: normal value, factors assessed

A

160-350 mg/dl

I

NURA 606 Adv Health Assessment (9 decks)

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