Renal reduced Flashcards

Question

Renal Failure Postioning

Answer 1

1. **Hypocalcemia** → prone to **fractures** 2. **Uremic neuropathies** → prone to nerve injuries 3. Distal symmetrical **mixed motor** and **sensory** neuropathy 1. **median** **nerve** and **common** **peroneal** are most often affected

Answer 2

**Accelerated** induction & emergence seen with severe anemia d/t ↓ solubility **_Best agents to use_** 1. _Isoflurane_ and _Desflurane_: * Do not depend on kidneys for elimination **_Contriversial_** 1. _Sevoflurane_: → some practitioners remain concerned regarding Compound A & free fluoride ion **_AVOID_** 1. _Halothane_: * causes high K+ & acidosis → myocardial irritability 2. _Enflurane_: → fluoride concern

Answer 3

1. **Short acting opioid** + O2 + **Agent** +/- N₂O * **Opioids** can accumulate 2. **For persistant intra-op HTN:** * ↑ inhaled agent, NTG, hydralazine , ß-blockers (↑ DOA possible) 3. **Ventilate to MAINTAIN NORMOCAPNIA** * **VERY important!!!!!!!** * **Hypoventilation** exacerbates acidosis * **Hypercapnia** predisposes to cardiac arrhythmias * **Alkalosis** shifts oxy-hgb curve to LEFT → less O2 available to tissues * offsetting compensation 4.

Answer 4

**Renal excretion is the _primary route of elimination_** * Edrophonium (75%) * Neostigmine (50%) * Pyridostigmine (75%) **Renal failures effect on these drugs:** 1. **Prolonged half life** 2. Prolonged at least as much as the relaxants 3. Normal dosing is usually given (Not on slides: Do **NOT** need to eliminate the glycopyrolate because it will also have a prolonged duration of action)

Answer 5

1. USE **pre-hydration** in renal patients who are NOT on dialysis * ½ NS or NS→ **NO Lactated Ringers** → has 4 meq/L of K+ 1. Use **500 ml bag**s & **microdrip** (**60** gtts) 2. Maintain urine output at **0.5** cc/kg/hr 1. _Lasix_ **1-5 mg** if U/O drops 3. Urine output is **NOT** predictive of postoperative renal insufficiency 4. **_Anuric patients_** 1. display a narrow margin of safety for fluids 2. **CHF** or **Pulmonary Edema** may develop postop if not careful with fluids

Answer 6

1. **Minor** surgical procedures can be monitored by **noninvasive** means 1. Do **NOT** measure BP in arm with fistula 2. Invasive monitoring may be needed for diabetic with advanced renal disease 2. **A-line** needed for major cases 3. **CVP** or **PA pressures** for cases with a large anticipated fluid shifts or blood loss 1. bowel surgery 4. Also consider **TEE**

Answer 7

1. **Good to use d/t great vasodilation** 2. Caution with a **coagualopathy** (check coags) 3. In combo with **metabolic acidosis** regional may ↓ seizure threashold 4. No not use if they have an infection 5. **_Used for_** * **Placement of AV Fistula** : Brachial Plexus Block/Sedation + Local

Answer 8

GOAL = adequate intravascular fluid volume & minimizing CV depression **vasopressors are used sparingly** 1. **α-adrenergic**: * phenylephrine = greatest ↓ in renal circulation 2. **β-adrenergic**: 1. ↑ myocardial irritability and NO renal vasoconstriction 3. **AVOID hypotension with prevention techniques** * However in severe septic shock, severe hypotension ect, renal autoregulation is impired * Norepinephrine may actually be renal protective if it increases MAP \> 60mmHG

Answer 9

1. Renal patienst should have dialysis the day before or day of surgery 2. **NO LR** → use K+ free solution and a **microdrip** (60 gtts) 3. **AV Fistula:** do not use extremity for BP or IV 4. **CV disease is likely:** * Step up your monitoring! * A-line, Swan → Maintain LV preload 5. **Treatment of Hypotension:** * Treat with a direct α (**phenylephrine**) * but remember renal constriction * **β-**can cause cardiac irritability 6. **GI prophylaxis:** * H2 blockers (but they are not cleared very well) * no metoclopramide 7. **Muscle Relaxants:** * no/little renal elimination

Answer 10

1. **Recurarization** can occur d/t ineffective metabolism of other drugs (antibiotics) * Gentamycin 2. **HTN is common** → treat w/ NTG & SNP 3. **ECG** monitoring 4. Continue **O₂** 5. **Antibiotic** Continuation

Answer 11

1. Most common urologic procedure 2. Indicated for: 1. Hematuria (bleeding in the urine) 2. recurrent urinary infections 3. urinary obstruction (renal stones) 4. Other surgeries performed under cysto bladder biopsies, extraction of renal stones, placement of ureteral stent 3. Procedure: 4. Endoscopy & Cystoscopy * _Endoscopy_ = visualize & evaluate the ureter, kidney, bladder, prostate & urethra to diagnose and treat renal calculi, hematuria, trauma, cancer 1. _Cystoscopy_ = passage of a rigid scope through the urethra into the bladder 5. **_Can be done under MAC_** with **2% lidocaine jelly** can be used (and can be done under MAC) 6. **_Bladder distention_** requires regional or general anesthesia 7. Done in **Lithotomy** position

Answer 12

_Most common nerve injuries_ 1. Common peroneal nerve injury 2. Saphenous nerve damage 3. Obturator and femoral nerve injury 4. Sciatic nerve Positioning considerations/risks 1. Both legs need to come up **together** 2. Decrease **FRC** and **atelectasis** possible 3. Increased **venous return** may exacerbate CHF 4. Bladder perforation * May go unnoticed under GEN * Consider if: * unexplained HTN, tachycardia, hypotension * Shoulder pain is referred bladder pain * Fever/bacteremia * Bleeding

Answer 13

All major legs nerves except LFC (Sciatic, common peroneal, femoral, saphenous, and obturator)

Answer 14

**Most often General with an LMA** (if not a full stomach) 1. Short procedure length (**15-20** minutes) 2. Most patients apprehensive **Regional anesthesia** 1. Spinal is preferred d/t faster onset 1. Studies show no need to wait for spinal onset before moving into lithotomy 2. **Need a T10 level block** 1. _Spinal_ (0.75% bupivacaine) * (**10-12** mg if **\> 1** hour) or (**7.5** ml if **\< 1** hour) 2. _Lumbar_ _Epidural_ (**1.5 - 2%** lidocaine w/ epi **15-25ml**) * Supplement with **5-10** ml bolus as needed 3. _Local_ (**2%** lidocaine jelly with IV sedation) 3. **Sensory level T10 block** 1. Does not abolish **obturator** **reflex** 2. **electrocautery** may stimulate obturator nerve d/t proximity of nerve to bladder wall 3. Will see **external** **rotation** & **adduction** of **thigh** 4. Can only block w/ **muscle paralysis** → but do NOT want to give MR with regional

Answer 15

**Transurethral Resection of Prostate** 1. **most common GU procedures in men \> 60** 1. Lateral and medial **lobe** of prostate removal alleviates **urinary obstruction** from BPH 2. **Preceded by cystoscopy** * **resecto-scope** inserted into urethra/bladder allows both cutting and coagulation of tissue and vessels. 3. **Three types** 1. **M-TURP** (monopolar) MUST irrigate with **NON**-**electrolyte** solution (problem = TURP syndrome) 2. **B- TURP** (bipolar) can irrigate with **0.9% NS** 3. **L-TURP** (laser) NO fluid irrigation needed 4. **Continuous irrigation is needed to** * Distend bladder * Wash away blood and tissue * Maintain visibility 5. **Absorption of the irrigant can lead to** * Pulmonary edema * Hyponatremia (can be fatal - sezures) * Cardiac and retinal toxic effects * Increased blood volume * Hyperglycemia * TURP syndrome 6. **Hypothermia** * Results from Large volumes of irrigating fluids * Warm fluids to body tem

Answer 16

1. Position: **Lithotomy** w/ slight Trendelenburg 2. Pre-op medication 1. Sedation as needed for anxiety 2. Antibiotics per surgeon/often: * Gentamycin 80 mg IV slowly (can potentiate our NM blockade → may start w/ lower dose of Roc 3. **EBL ≈ 500mls** (2-4ml/min of resection time) * Prolonged procedure? get a BG to check Hgb * Consider Type and cross 4. **General** * Acute hyponatremia from TURP syndrome may delay emergence from GA 5. **Regional** 1. **Spinal** –technique of choice w/ M-TURP 2. **T-10** sensory block required 3. Allows for monitoring of: * accidental **bladder perforation** (shoulder pain) * **mental status ∆s** d/t water intoxication/fluid overload (start to slur their words) 4. ↓ risk of post-op **venous** **thrombosis** 5. ↓ **blood loss** 6. **M & M:** No difference between GEN and Spinal

Answer 17

**Irrigation opens venous sinuses in prostate & allows _systemic absorption of irrigating fluid_** 1. Usually caused **glycine**, **sorbitol**, or **mannitol** 2. **M-TURP** (monpolar = non electrolyte hyposmplar solution) 1. Cant use electrolyte solutions because they **disperse** the electrocautery current 3. B-TURP and L-TURP use NS = not an issue **_Signs of hypo-osmolarity or low sodium:_** * headache, restlessness confusion, seizure * cyanosis, dyspnea, * arrhythmias, hypotension with bradycardia, ***Prevention of TURP Syndrome*** * Height of irrigating sol. **MUST be \< 60 cm** above surgical table * **Limit resection time to less than 1** * Amount of fluid absorbed is proportional to surgical time * Approx **20ml/min** of resection time * Longer case = increased risk **_Treatment of TURP Syndrome_** 1. **Early recognition is Key** * Look for fluid overload, lung sounds, seizures 2. **Fluid restriction** 3. **Loop diuretic** 4. **Hyper**tonic solution if hyponatremia present * **100** ml **3%** saline over **1-2** hours * Administer based on patient's serum Na+ → **ideally \>120** 5. **Treat seizures** with **midazolam**, **thiopental**, or **phenytoin** * if glycine used consider a trial of magnesium 6. **Intubate**

Answer 18

**_Extracorporeal Shock Wave Lithotripsy (ESWL)_** 1. Disintegrate calculi in upper ⅔ of ureters/kidneys 2. Shock waves focused at renal stones 1. High energy units = 1^stgeneration = patient in water 2. Low energy unit = 2^nd + 3^rd = lithotrypsers w/o water bath * small water-filling coupling device and tightly focused sound beam **_Patient considerations_** 1. Patients with **pacemaker or AICD** are at risk to develop **arrhythmias** * turn off right before and turn on right after and have a backup pacer ready 2. Shock waves synchronized to **20 ms after R wave** * During ventricular **refractory** period * **Bradycardia** can **prolong** **procedure** as shocks are coupled to the R wave - may have to increase HR to make the procedure more efficient

Answer 19

1. **Immobilization** is very important to limit shock to focal zone only 2. Very loud = earplugs (Us and patient) 3. **General (most frequently)** * Controlled Ventilation (controlled diaphragmatic excursion) * Avoids exposure to loud noise * Ligh GA with muscle relaxation * Can use High frequency Jet ventilation * General does not decrease the number of shocks or radiation exposure 4. **Regional only if you can ensure immobility** * Continuous **epidural** most common **T6** level required * **Disadvantage** = inability to control diaphragmatic movement (**stone** **moves** in and out of field) * Incidence of **hypotension** is higher secondary to the sitting position * If using epidural avoid injecting air (loss of resistance with saline) 5. **MAC** (Monitored anesthesia care) * **Flank infiltration** and Intercostal block with monitored anesthesia care w/ 3rd generation (still require immobilization)