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Anesthesia > Renal, Hepatic, & Neurologic Cases > Flashcards

Renal, Hepatic, & Neurologic Cases Flashcards

1
Q

What is used to categorize renal insufficiency?

A

renal function testing: BUN, creatinine, SDMA, UPC, BP, USG

  • IRIS staging guides anesthesia planning with increased risk at stage 2 and beyond
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2
Q

How do patients with renal insufficiency present?

A
  • appear unkempt and lethargic
  • PU/PD
  • poor appetite
  • poor appetite with weight loss
  • hypertensive
  • anemic
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3
Q

What balance is important to maintain in patients with renal disease?

A
  • fluids: balance in and out to maintain a fixed urine output
  • BP: hypertension does NOT protect from hypotension
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4
Q

What comorbidities are common in patients with renal disease?

A
  • heart disease
  • diabetes
  • hyperthyroidism in cats
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5
Q

How are cats with renal disease sedated before procedures?

A

half dose Gabapentin - high renal excretion!

  • can empirically increase if sedation is not achieved
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6
Q

How are prior anti-hypertensive medications given before an anesthetic event?

A

withhold within 12-24 hr of procedure

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7
Q

What sedation is commonly used for IVC placement (if necessary) in cats and dogs with renal disease?

A

DOGS - Butorphanol or pure mu agonist, cautiously use Dexmedetomidine at micro-doses, Alfaxalone

CATS - Butorphanol, Midazolam, Alfaxaone

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8
Q

What additional consideration is needed prior to anesthetic events in patients with renal disease?

A

HYDRATION - 1-2 hours of IV fluids at presentation

  • recommended to do these patients early to give adequate time for recovery
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9
Q

What are the 3 most common induction agents used in patients with renal disease? Which one needs to be used carefully?

A
  1. Ketamine - high renal excretion, good with multimodal therapy at low doses
  2. Propofol
  3. Alfaxalone
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10
Q

Other than various induction agents, how is inhalant usage minimized in renal patients?

A
  • Fentanyl or Ketamine CRIs
  • pure mu opioids
  • local blocks when possible
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11
Q

What monitoring equipment is ideal in patients with renal disease?

A
  • BP*
  • pulse oximeter
  • capnograph
  • temperature
  • ECG

have a dedicated anesthetist!

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12
Q

How is hypotension, bradycardia, hypoventilation, and hypothermia avoided/troubleshot in patients with renal disease?

A

treat aggressively with Dopamine CRI, cautiously with fluid boluses

treat if BP is low with anticholinergics (Atropine)

maintain at 40-50 mmHg

prewarm - hypothermia decreases MAC

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13
Q

What especially contributes to worse outcomes following anesthesia in patients with renal disease?

A

hypoxemia

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14
Q

What is especially important in the recovery period in patients with renal disease?

A

get them back to drinking and eating normally ASAP

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15
Q

What normal functions are altered by hepatic disease?

A
  • nutrient storage and supply
  • lipid, protein, and carb metabolism
  • albumin and coagulation factors
  • biotransformation and biliary excretion (barbiturates last longer!)
  • removal of ammonia and urea production
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16
Q

What is the aim to anesthesia for hepatic disease? What is generally avoided?

A

maintain hepatic perfusion and oxygenation

  • Acepromazine: irreversible, long-lasting
  • Dexmedetomidine: decreased hepatic perfusion
17
Q

What 3 things are done in anesthesia planning for patients with portosystemic shunts?

A
  1. avoid benzodiazepines that would worsen hepatic encephalopathy
  2. monitor blood glucose
  3. evaluate albumin levels pre and post
18
Q

What does the high energy demands of the brain result in?

A

no reserves of substrate or oxygen is present

19
Q

What is cerebral blood flow closely coupled with? Why is this significant with anesthesia?

A

cerebral metabolic rate of oxygen consumption

  • anesthesia can uncouple these and decrease glucose consumption
  • inhalant anesthetics alter autoregulation, where CBF becomes passively dependent on CPP
20
Q

What results from hypotension and hypertension to the brain?

A

MAP < 60 mmHg = cerebral ischemic

MAP > 150 mmHg = cerebral edema or hemorrhage

21
Q

What is cerebral perfusion pressure? What happens when it increases/decreases?

A

CPP = MAP - mean ICP
(proportional to CBF)

  • INCREASED = arteriolar vasoconstriction
  • DECREASED = arteriolar vasodilation
22
Q

What is indicative of intracranial disease?

A
  • abnormal mentation
  • dullness
  • obtunded
  • aimless wandering
  • circling
23
Q

What are 3 symptoms of increased intracranial pressure? How is this treated before anesthetic events?

A
  1. vomiting
  2. papilloedema (ocular disc swelling)
  3. pupillary dilation

reduce ICP with mannitol or hypertonic saline

24
Q

What is indicative of intracranial herniation? Is this treated?

A

Cushing’s reflex - increased BP, bradycardia, irregular ventilation

bradycardia is NOT treated

25
Q

What 2 consequences of anesthesia need to be avoided in patients with neurological disease? How are patients positioned

A
  1. hyperthermia - maintain normothermia to slight hypothermia
  2. hypercapnia - hyperventilate to ETCO2 of 33-35 mmHg (never below 30)

head elevated with no jugular compression

26
Q

What part of anesthesia should be minimized in patients with neurological disease? Why?

A

inhalants

cause increased CBF in the face of reduced demand of oxygen, resulting in a worsened ICP

27
Q

What 3 drugs are avoided/reduced in patients with neurological disease?

A
  1. Acepromazine - irreversible
  2. high induction doses of Ketamine
  3. inhalants
28
Q

What 5 drugs are used in patients with neurological disease?

A
  1. Propofol or Alfaxalone induction/TIVA
  2. pure mu agonists - reversible!
  3. analgesic Ketamine CRI
  4. Benzodiazepines
  5. low/minimal inhalants after hyperventilation commenced
29
Q

Hypertension and autoregulation of BF:

A
30
Q

What are the 3 levels of hypertension?

A

NORMOTENSIVE = SBP < 140 mmHg

  1. prehypertensive = 140-159 mmHg
  2. hypertensive = 160-179 mmHg
  3. severely hypertensive = > 180 mmHg
31
Q

What are the 4 most common treatment options for hypertension?

A
  1. Amlodipine
  2. Telmisartan
  3. Benazepril/Enalapril
  4. Atenolol
32
Q

How is hypotension determined in chronically hypertensive patients?

A

these patients have adapted to having high BP, so hypotension is considered at a higher value

Anesthesia (40 decks)

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