Renal III- procedures Flashcards
1
Q
Anesthesia considerations for AV Fistula or thrombectomy
A
- IV access on opposite side
- NS is fluid of choice
- induce with prop/etomidate, cisatracurium, and fentanyl
- RA possible with decreased LA doses
- may facilitate cannula introduction d/t vasodilation
2
Q
What is a cystoscope?
Retrograde pyelography?
A
- Cystoscope
- scope introduced into urethra and advanced into bladder to allow for inspection
- most common ly performed urologic procedure
- retrograde pyelography
- small catheters introduced into uretera orifices and advanced up to kidneys
- most pts have temorary stent in place post-op
3
Q
What are the anesthetic options for a cystoscope or pyelogram?
A
- Neuraxial
- T8-T10 required
- Spinal: 0.75% bupivicaine
- 10-12 mg if > 1 hour, 7.5 mg if <1 hr
- epidural: 1.5-2% lido w/epi
- 15-25 ml
- supplement with 5-10 mL boluses as needed
- GA
- ETT vs LMA (relaxation usually not required)
- minimal narcotic required
- +/- toradol, check with surgeon
- Can also be done under MAC or local with IV sedation
4
Q
What are the other considerations for cystoscopy?
A
- Lithotomy position
- nerve injury risks
- decrease FRC and atelectasis
- increase in venous return that can exacerbate CHF
- bladder perforation (HTN, tachycardia, or hypotension)
- bacteremia
- bleeding
5
Q
What is the TURP procedure?
What are the different types?
How much irrigation fluid is absorbed?
What is EBL for a TURP procedure?
A
- Alleviates urinary obstruction from BPH
- resectoscope inserted into urethra/bladder allowing for cutting and coagulation of tissues and vessels
- Types of Turp:
- monopolar- requires hypoosmolar irrigation solution which can absorb and cause turp syndrome
- bipolar turp- can use normal osmolarity fluids so absorption wont be as bad
- Laser turp
- Absorption: 20 ml/min of resection time
- height of irrigation fluid should be no more than 60 cm above table
- EBL = 2-4 ml/min of resection time (about 500)
6
Q
What can the fluid absorption during TURP procedure lead to?
A
- pulmonary edema
- hyponatremia
- cardic and retinal toxic effects
- increased blood volume
- hyperglycemia
- TURP syndrome- hyponatremia, hypoosmolality
- hypothermia
7
Q
What are the signs and symptoms of TURP syndrome?
A
- HTN leading to bradycardia or tachyarrhythmias and eventually MI
- CHF, decreased contractility leading to Pulmonary edema and hypoxemia
- CNS disturbances (HA, restlessness, confusion, transient blindness)
- hemolysis
- Hyponatremia:
- <120 CNS effects apparent
- <115 somnolence, hypotension, EKG changes
- <102 sz, coma
8
Q
How is TURP syndrome treated?
A
- Early recognition
- fluid restriction
- loop diuretics
- hypertonic saline
- CV support
9
Q
What are the anesthetic options for a TURP procedure?
A
- No difference in M&M btwn GA and RA
- GA- turp syndrome may delay emergence
- RA- technique of choice for M-TURP to maintain neuro exam throughout case
- T10 needed
- decreases post-op venous thrombosis and intra-op EBL
10
Q
What is ESWL?
A
- Procedure using shock waves focused on calculi in kidneys or upper 2/3 or ureters to disintigrate them
- high energy (1st generation); pt must be immersed in water bath
- low energy (2nd, 3rd gen); no water bath, uses tightly focused sound beam
- Tissue has same acoustic density as water, so waves travel without damaging tissue
- damages stone
- fragments can travel down (stent placed)
- tissue destruction can occur to lung/intestine if in the way
- shock is delivered in ventricular refractory period
11
Q
What are the contraindications for ESWL?
absolute?
relative
A
- Absolute contraindications
- pregnancy
- untreated bleeding disorders
- Relative
- AICD (must turn off)
- pacemaker (put on non-demand mode and have backup available)
- large calcified aortic or renal artery aneurysms
- morbid obesity
12
Q
What are the anesthetic options for ESWL?
A
- GA with controlled ventilation- provides immobilization and avoids noise exposure
- control of diaphragm movement (can use HFJV)
- only light GA required
- RA (T6 required)
- unable to control diaphragm and immovilize
- avoid air injection w/epidural
- MAC ok for low energy but still need immobilization
- **bradycardia will increase procedure length
- adequate hydration will have stone pass after
13
Q
Laser lithotripsy:
What is it?
Anesthetic options?
Risks?
A
- Laser beam carried through rigid ureteroscope to brake ureteral stones
- staff must wear protective eyewear
- GA w NMB advised
- T8-T10 required if choose to do RA
- Risk of ARF (post-renal)
- obstruction d/t stones, clots
- function can be restored if cause is found within hours
- pt may require percutaneous nephrostomy
14
Q
Radical nephrectomy:
What is removed?
Considerations?
A
- removal of kidney, adrenal gland, and perinephric fat
- Considerations:
- majority of pts are anemic, may need pre-op tx
- extensive blood loss expected d/t vascular and large tumors
- large bore PIV x2 + art line
- consider CVC
- L IJ, avoid R IJ d/t high proability of IVC involvement (5-10% of tumors extend into IVC and RA)
- NS/LR 4-5 ml/kg/hr
- anticipate hypotension w/ retraction of IVC
15
Q
Radical prostatectomy:
What is removed?
How is pt positioned?
A
- Removal of prostate, seminal vesicles, ejaculatory ducts, and part of the bladder neck
- remaining bladder neck is anastomosed to urethra over indwelling foley catheter
- Positioning:
- hyperextended supine position with abdominal incision
- iliac crest over break in OR table
- thoracoabdominal incision position
- hyperextended
- knee on non-op side flexed 90
- shoulder on op side brought over chest on arm rest
- Roboti assisted with steep T-berg
- Lithotomy for perineal approach
- hyperextended supine position with abdominal incision
16
Q
What are some additional considertions for a pt undergoing a radical prostatectomy?
A
- Large EBL- +/- autologous blood donation
- Large bore IV access + invasive monitoring
- NS4-6 ml/kg/hr
- nerve, soft tissue injuries
- VAE
- disease of elderly, consider comorbidities
17
Q
What are the anesthetic options for a radical prostatectomy?
A
- Neuraxial
- decreased VAE and EBL if used w/or w/out GA
- T8 required
- GA
- more commone, esp d/t uncomfortable positioning
- standard induction and maintenance
18
Q
What complications are seen with radical prostatectomy?
A
- hemorrhage
- hypothermia
- VAE
- common peroneal nerve injury d/t lithotomy position
- DVT–> PE
- pain is significante, consider epidural or PCA
19
Q
Pelvic lymph node disection:
Why is it done?
How is it done?
Anesthetic?
Considerations
A
- Pelvic lymph node disection to stage prostate cancer
- DaVinci Robotic laparoscopic
- GA (no N2O)
- Consideration:
- steep T berg + rotation for exposure can make ventilation difficult
- risk for hypothermia d/t irrigation fluids
20
Q
Bilateral Orchiectomy:
What is it?
Duration of procedure?
Anesthetic?
A
- Removal of testicles to control metastatic adenocarcinoma of the prostate
- Procedure time = 20 minutes
- single midline scrotal incision
- Most pts prefer GA w/ LMA, but can be done under local
21
Q
Bladder Cancer
How is the bladder removed?
What is removed with it in Males?
Females?
A
- Radical cystectomy- midline incision from pubis to xiphoid process
- urinary diversion required
- Removed in males:
- bladder
- lower ureters
- prostate
- seminal vesicles
- Removed in females
- bladder
- uterus
- ovaries
- anterior vaginal wall
22
Q
Anesthetic considerations for a pt with bladder cancer
A
- Pt may have received radiation pre-op
- 4-6 hr procedure
- large EBL; may use controlled hypotension
- art line, +/- CVL
- GA w/NMB
- RA as adjunct for post-op pain
- can cause hyperperistalsis which makes it difficult to create the urinary diversion
- difficult but important to assess UOP
- look at urine on field
23
Q
A
