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N506 Health Assessment > Renal/Hematology > Flashcards

Renal/Hematology Flashcards

1
Q

List some basic renal questions

A

Have you had kidney problems? Kidney failure, dialysis, 2+ kidney infections? Stones?
Are you on dialysis?
Bowel/bladder changes in past year?
Appetite/food changes in past year?

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2
Q

Intermittent hemodialysis is through a ____ and continuous peritoneal dialysis is through a ____

A

Intermittent through AV fistula (cephalic vein anastomosed to radial artery)
Continuous PD through implanted catheter

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3
Q

List situations that dialysis is required

A

Oliguria, fluid overload
Hyperkalemia, severe acidosis, metabolic encephalopathy
Pericarditis, coagulopathy
Refractory GI symptoms, drug toxicity

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4
Q

When deciding if we should take the patient to surgery that is on dialysis, what do we need to consider?

A

Dialysis should occur the day of surgery or the day before
Consider amount of fluid taken off, weights
Serum K < 5.5!!

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5
Q

Do you give meds before or after dialysis?

A

AFTER because low-molecular weight, water soluble, non protein bound drugs are readily cleared by dialysis

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6
Q

What are signs of uremic encephalopathy?

A 
Asterixis
Myoclonus
Lethargy
Confusion
Seizures, coma
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7
Q

Why do renal failure patients have anemia? Why do they tolerate it (exception CAD)?

A

Dec erythropoietin production, dec RBC production and lifespan, GI blood loss, hemodilution, blonde marrow suppression, excess PTH replaces bone marrow with fibrous tissue
Tolerate because increased 2,3-DPG and metabolic acidosis cause a shift to the right in oxyhemoglobin curve

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8
Q

Why do renal failure patients have prolonged bleeding time?

A

Impaired platelets
Dec platelet factor III activity
Dec adhesiveness and aggregation
Release of defective vWF

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9
Q

What might someone with renal failure have on their cardiovascular assessment?

A

Inc CO (to compensate for dec O2 carrying capacity)
HTN
Deposition of calcium (on heart valves)
Arrhythmias
Uremic pericarditis, CAD, PVD, CHF with pulmonary edema

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10
Q

What will you assess for someone with renal failure to determine fluid volume status?

A

Body weight
Vitals (orthostatic hypotension, tachycardia)
Atrial filling pressures
Look for edema (ankles), listen for rales

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11
Q

What might someone with renal failure have on their pulmonary status?

A

Inc minute ventilation (to compensate for metabolic acidosis)
Inc pulmonary extravascular water -> interstitial edema -> widened alveolar O2 gradient
Butterfly wings on CXR due to inc permeability of alveolar capillary membrane, pleural effusion

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12
Q

What might someone with renal failure have on their endocrine assessment?

A

Insulin resistance, poor glucose tolerance
Hyperparathyroidism, prone to fractures
Abnormal lipid metabolism (atherosclerosis)
Kidneys aren’t degrading hormones and proteins normally leading to increased circulating PTH, insulin, glucagon, GH, LH, PL

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13
Q

What might someone with renal failure have on GI/Liver assessment?

A 
GI hemorrhage
Anorexia, N/V
Hypersecretion of gastric acid, delayed gastric emptying (autonomic neuropathy)
High incidence of Hep B/C
Ascites with dialysis
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14
Q

What should you assess for in a neurologic assessment for a patient with renal failure?

A

Uremic encephalopathy (asterixis, myoclonus, lethargy, confusion, seizures, coma)
Autonomic/peripheral neuropathy
Disequilibrium syndrome (CNS disturbance after decrease in ECF osmolality)
Dementia

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15
Q

What should you assess for in a hematological assessment for a patient with renal failure?

A 
Anemia
Impaired platelets, prolonged bleeding
Impaired WBC function (infection)
Release of defective vWF
Hypocomplementemia with dialysis
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16
Q

What are some drugs contraindicated in renal failure?

A

(Due to elimination by kidneys)
Gallamine
Phenobarbital
LMWH

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17
Q

What are the three basic physical assessments done on EVERY patient?

A

Airway
Cardiac
Pulmonary

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18
Q

What if the best indicator of GFR? BUN or creatinine clearance?

A

Creatinine clearance, but it takes 24 hours

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19
Q

What are three reasons that BUN can be abnormal despite a NORMAL GFR?

A

High protein diet
GI bleed
Febrile illness
Most common cause of inc BUN is CHF secondary to reabsorption of BUN

20
Q

____% increase in plasma Cr reflects a corresponding decrease in GFR

A

50%

Suggesting (but not indicative) of ARF

21
Q

___ hour lag time after a change in GFR before increase Cr levels are seen

A

8-17 hours

22
Q

What is creatinine clearance? Normal level?

A

24 hour collection, most accurate, approximates GFR

Normal 100-120 mL/min

23
Q 
Creatinine clearance of..
Dec renal reserve?
Mild renal impairment?
Moderate insufficiency?
Renal failure?
ESRD?
A 
Normal 100-120 mL/min
Dec renal reserve 60-100
Mild Renal impairment 40-60
Moderate insufficiency 25-40
Renal failure <10
24
Q

Common abnormal labs with renal failure?

Na, K, Mg, Ca, Albumin, BG, acid/base?

A 
HYPOnatremia
HYPERkalemia (hypo with dialysis)
HYPERmagnesemia
HYPOcalcemia
HYPOalbuminemia
HYPERglycemia
Metabolic acidosis
25
Q

Treatment of hyperkalemia (symptomatic or over 6.5 mEq/L)? Onset? Duration?

A

Ca gluconate 10%, 10-20mL, antagonizes K effects on cardiac muscle, immediate onset, brief DOA, avoid with dig
Na Bicarb 50-100 mEq, shift K into cells, prompt onset, short DOA
Glucose 50mL of 50% and 10u regular insulin, shift K into cells, prompt onset, DOA 4-6 h
Dialysis removes K from body, immediate onset
Ion exchange resin removes K from body, onset 1-2h

26
Q

What is the best screening test for coagulation abnormalities? What is normal? Why would it be abnormal?

A

Bleeding time is best, it can be increased despite normal PT/PTT
Normal 3-10 min
Abnormal due to defective vWF
Treat with desmopressin or cryoprecipitate

27
Q

What can EKG tell us in someone with renal failure?

A 
Hyper/hypo-kalemia
Hypocalcemia
Ischemia
Conduction blocks
LVH
28
Q

What can echo tell us about someone with renal failure?

A

Ventricular EF
Hypertrophy
Wall motion abnormalities
Pericardial fluid

29
Q

What are basic hematologic system questions?

A

Anemia, leukemia, clotting/bleeding problem?
Meds: ASA, vitamin E, ginseng, garlic?
Family hx of bleeding problems?
Prolonged bleeding from cutes, nosebleed, bruises, tooth extractions, surgery?
Ever had a blood transfusion bc of bleeding?

30
Q

What is the equation for arterial oxygen content (CaO2)?

A 
CaO2 = Hgb x 1.39 x Sats + (PaO2 x 0.003)
1.39 = O2 bound to hemoglobin
Sats = saturation of hemoglobin with O2
PaO2 = art partial pressure of O2
0.003 = dissolved oxygen ml/mmHg/dl
31
Q

In chronic anemia, for decreases in CaO2, how does the pt compensate?

A

Dec SVR, inc CO, inc plasma volume
Inc 2,3-DPG
Redistribution of blood flow to organs with higher extraction ratio
Inc extraction ratio in vascular beds

32
Q

What factors are considered in developing a minimum acceptable Hgb and Hct?

A 
Duration: chronic/acute
Etiology
IV fluid volume
Urgency of surgery, anticipated blood loss
Co-exsisting disease
33
Q

Hemolytic anemia: what are perioperative risks/concerns?

A

Inc risk of tissue hypoxia
Splenectomy inc risk of peri-op infection
Erythropoietin prescribed for 3 days pre-op

34
Q

Sickle cell trait vs. disease?

A

Trait: hetero carriers may have mild anemia
Disease: homozygous, contain 70-98% Hgb S (less Hgb A), anemia is well tolerated, O2 delivery to tissues due to R shift of oxyhemoglobin curve with Hbg S

35
Q

Sickle cell disease has a 30% complication rate in surgery, due to what?

A

Stroke, MI
HF, pulm HTN
Hepatic/splenic sequestration
Renal failure

36
Q

Sickle cell disease surgical goal?

A

Avoid situations leading to hypovolemia, hypoxia, and stasis (limit tourniquet use)

37
Q

How do you avoid sickle cell crisis?

A 
Maintain normothermia (cold will vasoconstrict, sickling)
Hydrate (dehydration leads to sickling)
Maintain oxygenation
Avoid acidosis (leads to sickling)
Position to prevent stasis
38
Q

Thalassemia perioperative risks?

A

High output CHF (arrhythmias)
Compensatory RBC production (craniofacial deformity makes DVL challenging)
Complications from chronic transfusions
Hypersplenism can result in thrombocytopenia, inc risk of infection

39
Q

What are complications of iron loading from chronic transfusions?

A 
DM
Adrenal insufficiency (less response to pressers)
Liver/coag abnormalities
Hypothyroid, hypoparathyroid
Arrhythmias, HF
40
Q

Aplastic anemia (RBC has short lifespan due to failure of bone marrow to make normal RBC): why do we want a CBC pre-op?

A

Neutrophil, RBC, and platelets can be extremely low, they may need a transfusion

41
Q

Aplastic anemia periop risks/concerns?

A

Infection/sepsis (REVERSE isolation)
Hemorrhage (GI/brain)
LV dysfunction (due to high output)
Co-exsisting abnormalities (fanconi anemia)
Difficulty cross-matching after multiple transfusions
Avoid nasal intubation
Abrupt hemodynamic response to induction

42
Q

Porphyria

A

Group of errors of metabolisms, mild anemia can result
Porphyrin is essential for O2 transport/storage
Inc heme requirements results in accumulation of pathway intermediates preceding enzyme block

43
Q

How is porphyria activated?

A

Activated via drugs, diet, and steroids

Trigger by inducing ALA synthetase or interfering with negative feedback in final common pathway

44
Q

Porphyria attack symptoms?

A 
Severe abdominal pain/ GI disturbance
ANS instability
Electrolyte disturbances
CNS disturbance
Life threatening muscle weakness
45
Q

What drugs are UNSAFE in patients with porphyria?

A 
Barbiturates
Phenytoin
Sulfonamide
ETOH
Diazepam
Also avoid: Etomidate, nifedipide, ketorolac
46
Q

What factors are defective/absent in hemophilia A, B, and Von Willebrand’s?

A

Hemophilia A: factor VIII (abnormal PTT)
Hemophilia B: factor IX (abnormal PTT)
Von Willebrand’s: vWF, factor VIII (prolonged bleeding)

N506 Health Assessment (7 decks)

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