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Principles 2 > Renal Syndromes & Drugs > Flashcards

Renal Syndromes & Drugs Flashcards

1
Q

What is Uremic Syndrome?

A

-Extreme form of chronic renal failure with surviving nephron population and GFR dropping to < 10%
-Reflects kidneys inability to perform functions of water and electrolyte balance
-BUN indicator of severity (Serum creatinine poorly correlates with S/Sx)

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2
Q

What are S/Sx of Uremic Syndrome?

A

Anorexia
nausea/vomiting
pruritus
anemia
fatigue
coagulopathy

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3
Q

What is the treatment for Uremic Syndrome?

A

Dietary protein restriction based on presumption that low protein diet results in decreased protein catabolism and urea production

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4
Q

What are complications of Uremic Syndrome?

A

Hyponatremia
Hyperkalemia
Metabolic acidosis
Heart failure
HTN
Myocardial dysfunction
Pulmonary edema
Central hyperventilation
Anemia
Delayed gastric emptying
Encephalopathy
Seizures

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5
Q

What is Nephrolithiasis?

A

Stone formation
-Pathogenesis poorly understood
-Most are Calcium Oxalate
-Stones in renal pelvis = painless
-Stones in ureters = painful
-Hematuria is common during passage of stone
-Ureteral obstruction leads to S/Sx of renal failure.
-Risk of sepsis due to buildup of waste products due to urine obstruction.

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6
Q

What is an S-Wall procedure?

A

Breaks up a kidney stone.
-Special OR table that beats against back, sending US wave into kidney to break up stone.
-Can cause irritation to heart. Leads to arrhythmias. Risk of R on T.
-Can synch this with the EKG.

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7
Q

What is TURP Syndrome?

A

TURP = Transurethral Resection of the Prostate.
-Syndrome occurs when patient absorbed too much of the irrigation fluids during the procedure.
-Intravascular fluid volume shifts and plasma solute effects
-Solute changes may alter neurological function independent of volume related effects
-Mild to severe

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8
Q

What are the S/Sx of TURP Syndrome? (general)

A

Related to water intoxication:
-Mild: Restlessness, nausea, shortness of breath, dizziness
-Severe: Seizures, coma, HTN, bradycardia, CV collapse

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9
Q

What are the disadvantages of the Glycine 1.5% solution used for TURP?

A

Hyperglycinemia
Hyperammonemia
-These cause the TURP Syndrome S/Sx

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10
Q

What are the Cardiovascular S/Sx of TURP Syndrome?

A

-Hypertension
-Reflex bradycardia
-Pulmonary edema
-Cardiovascular collapse
-ECG changes (wide QRS, elevated ST segment, ventricular arrhythmias)

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11
Q

What are the causes of the CV S/Sx in TURP Syndrome?

A

-Rapid fluid absorption
-Reflex bradycardia (secondary to hypertension or increased ICP)
-Third-spacing secondary to hyponatremia and hypo-osmolality

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12
Q

What are the Respiratory S/Sx of TURP Syndrome?

A

-Tachypnea
-Hypoxemia
-Cheyne-Stokes breathing

Caused by Pulmonary Edema

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13
Q

What are the Hematologic S/Sx of TURP Syndrome?

A

-Disseminated intravascular coagulation
-Hemolysis

Caused by Hyponatremia and Hypo-osmolality

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14
Q

What are the Neurological S/Sx of TURP Syndrome?

A

Nausea
Restlessness
Visual disturbances
Confusion
Somnolence
Seizure
Coma
Death

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15
Q

What are the causes of Neurological symptoms with TURP Syndrome?

A

-Hyponatremia and hypo-osmolality causing cerebral edema and increased ICP,
-Hyperglycinemia (glycine is an inhibitory neurotransmitter that potentiates NMDA receptor activity)
-Hyperammonemia

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16
Q

What are the Renal effects of TURP Syndrome?

A

Renal Failure.

Caused by Hypotension and Hyperoxaluria (Oxalate is a metabolite of glycine)

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17
Q

What are the Metabolic effects of TURP Syndrome?

A

Acidosis.

Caused by deamination of glycine to glyoxylic acid and ammonia.

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18
Q

What are factors that affect the Absorption of the fluids during TURP?

A

-Number and size of open venous sinuses (resection of prostate opens venous sinuses)
-Duration of resection
-Hydrostatic pressure of the irrigating fluid (height of bag on IV pole)
-Venous pressure at the irrigant-blood interface.

Rate of absorption determines whether or not we see syndrome.

19
Q

How do you avoid absorption of the fluid during TURP?

A

-Resection time < 1hr
-Bag no > 30cm from bed at beginning and 15 cm during final stages of resection
-Avoid hypotonic solutions
-Treat Regional Anesthesia induced HOTN (use spinals with these)

20
Q

What is the treatment for TURP Syndrome?

A

-Ensure oxygenation and circulatory support.
-Notify surgeon and terminate procedure as soon as possible.
-Consider insertion of invasive monitors if cardiovascular instability occurs.
-Send blood to laboratory for evaluation of electrolytes, creatinine, glucose, and arterial blood gases.
-Obtain 12-lead electrocardiogram.
-Treat mild symptoms (with serum Na+ concentration >120 mEq/L) with fluid restriction and loop diuretic (furosemide).
-Treat severe symptoms (if serum Na+ <120 mEq/L) with 3% sodium chloride IV at a rate <100 mL/hr.
-Discontinue 3% sodium chloride when serum Na+ >120 mEq/L.

21
Q

What are the advantages to using Neuraxial Anesthesia for TURP?

A

-Ability to assess the patient’s level of consciousness for TURP syndrome
-Ability to assess chest pain, SOB caused by myocardial ischemia and volume overload
-Ability to assess abdominal pain caused by bladder perforation
-Decreased vascular resistance will less possibility of hypervolemia
-Controversial if neuraxial blockade decreases blood loss during TURP

22
Q

What are the disadvantages to using Neuraxial Anesthesia for TURP?

A

-Moderate to severe HOTN can occur and potentiated in patients taking alpha-adrenergic antagonists for BPH
-Placement can be difficult due to arthritic changes in aging population
-Decreasing venous resistance increases amount of irrigant that is absorbed through open venous sinuses
-Dysphoria from benzos, narcotics or other CNS depressants given

23
Q

What is the difference between Extraperitoneal and Intraperitoneal Bladder Rupture?

A

-Extraperitoneal is most common type (80% of cases) - usually secondary to adjacent pelvic fracture or avulsion tear
-Intraperitoneal usually iatrogenic or secondary to penetrating injury.
-Blunt trauma more likely to result in intraperitoneal rupture in children than in adults
-Intraperitoneal rupture requires surgical repair and extraperitoneal rupture can be treated conservatively
-Intraperitoneal rupture can develop chemical peritonitis

24
Q

What are the S/Sx of Extraperitoneal Bladder Rupture?

A

Discomfort:
-Periumbilical
-Inguinal
-Suprapubic

Periumbilical/inguinal tissue distension

25
Q

What are the S/Sx of Intraperitoneal Bladder Rupture?

A

Discomfort:
-Chest
-Upper abdomen
-Shoulder tip (diaphragmatic irritation)

Nausea and vomiting
Abdominal rigidity (if peritonitis develops)
Shortness of breath
Diaphoresis
Hiccups

Definitely requires surgical repair

26
Q

What is the effect of Volatiles on Renal Function?

A

-Methoxyflurane & enflurane: Only volatiles to directly cause renal dysfunction
-Indirect effects combined with hypovolemia, shock, nephrotoxin exposure produce renal dysfunction
-Iso & Des have no impact
-Sevo is questionable with Compound A (not rly based in literature). Keep to 2 MAC hours.

27
Q

Which is better for kidney function, GA or RA?

A

No studies show improved outcome/protection with either.

28
Q

What is the effect of Thiopental when used in a patient with renal failure?

A

-Historic agent (Barbiturate)
-Free fraction of an induction dose of thiopental is almost doubled in patients with renal failure
-Severe hypotension

29
Q

What is the effect of Ketamine when used in a patient with renal failure?

A

-Less extensively protein-bound than thiopental, and renal failure appears to have less influence on its free fraction
-Don’t use for induction of GA with renal patients
-However, can be used in pain mgmt of renal patients. 30-50 mg, or small drip of it for short period of time is helpful. Subclinical doses so don’t get hallucinogenic effects
-Provides dissociative amnesia and patient keeps breathing.

30
Q

What is the effect of Etomidate when used in a patient with renal failure?

A

-75% protein-bound in normal patients, has a larger free fraction in patients with ESRD.
-Cardiac protective drug.
-Good to use with ESRD due to maintaining cardiac stability.

31
Q

What is the effect of Propofol when used in a patient with renal failure?

A

-Rapid hepatic biotransformation to inactive metabolites that are renal excreted
-Dose dependent: can use it, but maybe lower dose
-Patients will respond like a hypovolemic state. Labile VS

32
Q

What is the effect of Benzos when used in a patient with renal failure?

A

-CKD increases the free fraction of benzodiazepines in the plasma, and this potentiates their clinical effect
-Decrease the dose

33
Q

What is the effect of Dexmedetomidine when used in a patient with renal failure?

A

-Primarily metabolized in the liver
-Pretty safe in renal patients
-effects may last longer (prolonged)

34
Q

What is the effect of Morphine when used in a patient with renal failure?

A

-Single-dose studies demonstrate no alteration in its disposition
-Chronic administration results in accumulation of its metabolite, leading to potent analgesia and sedation.

35
Q

What is the effect of Meperidine when used in a patient with renal failure?

A

Not recommended for use in patients with poor renal function.
-Metabolites can accumulate

36
Q

What is the effect of Codeine when used in a patient with renal failure?

A

Can be used short-term, but not prolonged use.
-Potential for causing prolonged narcosis

37
Q

What is the effect of Fentanyl when used in a patient with renal failure?

A

Better choice of opioid for use in ESRD because of its lack of active metabolites, unchanged free fraction, and short redistribution phase.

38
Q

What is the effect of Alfentanil when used in a patient with renal failure?

A

No change in its elimination half-life or clearance in ESRD and is extensively metabolized to inactive compounds.

39
Q

What is the effect of Remifentanil when used in a patient with renal failure?

A

Renal failure has no effect on the clearance of remifentanil, but elimination of the principal metabolite, remifentanil acid, is markedly reduced.

40
Q

What is the effect of Muscle Relaxants when used in a patient with renal failure?

A

-Most likely to produce prolonged effects
-Most are dependent on renal excretion
-Except: succinylcholine, atracurium, cis-atracurium, and mivacurium appear to have minimal renal excretion of the unchanged parent compound

Other factors:
-coexisting acidosis and electrolyte disturbances, as well as drug therapy

Succ:
-Be sure to check serum potassium levels

41
Q

What is the effect of Long-acting Muscle Relaxants (Ex: Pancuronium) when used in a patient with renal failure?

A

Increased elimination half-life, reduced plasma clearance, and prolonged duration of effect.
-Avoid in Renal patients

42
Q

What is the effect of Intermediate acting Muscle Relaxants when used in a patient with renal failure?

A

-Atracurium and cisat undergo Hoffman degradation (might be better choice)
-Vec duration of action prolonged
-Roc single dose study has reported conflicting reports

However, if using Vec or Roc can decrease dose or increase interval. Adequately monitor TOF. Patients will have abnormal rxns.

43
Q

What is the effect of Short-Acting Muscle relaxants when used in a patient with renal failure?

A

Mivacurium is eliminated by plasma pseudocholinesterase at a rate slower than succ.

Principles 2 (45 decks)

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