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AS - N931 Advanced Principles of Anesthesia > Urologic > Flashcards

Urologic Flashcards

1
Q

The kidneys receive ___% CO

A

20-25%

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2
Q

How do the kidneys maintain homeostasis?

A

Filtration
Reabsorption
Tubular excretion

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3
Q

Normal GFR

A

125mL/min

Up to 99% filtrate reabsorbed

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4
Q

Renal Hormones

A 
Aldosterone
ADH
Angiotensin
ANP
Vitamin D
Prostaglandins
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5
Q

Bowman’s Capsule

A

Filtration

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6
Q

Proximal Tubule

A

Reabsorption

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7
Q

Loop of Henle

A

Concentration

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8
Q

Distal Tubulue

A

Reabsorption

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9
Q

Collecting Duct

A

Last chance to concentrate urine & reabsorb H2O

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10
Q

Urine Specific Gravity

A

1.01 - 1.025

pH 4.6-4.9

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11
Q

Anesthesia Impact

A

Anesthetic drugs depress normal renal function
↓RBF 30-40%
Autoregulation impairment
↓GFR, urinary flow, & electrolyte secretion
Similar changes after spinal or epidural anesthesia
- Sympathetic blockade & ↓BP

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12
Q

Volatile Anesthetics Effect

A

Mild ↑renal vascular resistance
Compensatory mechanisms in response to ↓CO/SVR
Goal - preop hydration, ↓volatile agents, maintain BP, & attenuate ↓RBF/GFR

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13
Q

Sevoflurane

A

Associated w/ elevated fluoride levels
Degraded by absorbents → compound A (vinyl ether)
Compound A nephrotoxicity
↑FGF to prevent risk 1L/min 2 MAC-hours max
↓gas concentration
Utilize carbon dioxide absorbents

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14
Q

Isoflurane

A

Not associated w/ nephrotoxicity

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15
Q

Desflurane

A

Resists biodegradation

Not associated w/ nephrotoxicity

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16
Q

Fluoride Ion Toxicity

A

Fluoride interferes w/ Na+/Cl¯ active transport in the loop of Henle
Potent vasoconstrictor → negative effects on CV
Inhibit enzyme systems (ADH)
Nephrotoxicity - proximal tubular swelling & necrosis

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17
Q

Nephrotoxicity S/S

A 
Polyuria
Hypernatremia
Serum hyperosmolality
↑BUN/creatinine
↓creatinine clearance 
Related to dosage, duration, & peak fluoride concentrations
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18
Q

Acute Kidney Injury

A

Renal functional or structural abnormality that occurs w/in 48hrs
↑creatinine 0.3mg/dL or 50%
UOP <0.5mL/kg/hr x 6 hours

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19
Q

Pre-Renal AKI

A

Renal hypoperfusion w/o parenchymal damage
- Hemorrhage, vomiting/diarrhea, diuretics, sepsis/shock, CHF, NE, NSAIDs, ACEi
Early identify & treatment causes = BEST outcomes

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20
Q

Intra-Renal AKI

A

Damage to renal tissue
- Tubular injury d/t hypoperfusion, myoglobin, chemotherapy, infections, lymphoma, toxemia (pregnancy), vasculitis
Most difficult to treat w/ worst oucomes

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21
Q

Post-Renal AKI

A

Due to urinary tract obstruction
- Renal calculi, peritoneal mass, prostate/bladder urethra tumor, fibrosis, hematoma, strictures
Good prognosis w/ early identification

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22
Q

AKI Risk Factors

A

Hypovolemia, electrolyte imbalance, contrast dye
Aging - preop renal dysfunction or >50yo
Comorbidities - cardiac or hepatic failure
Surgical procedures - aortic cross-clamp, cardiac bypass, arteriography, intra-aortic balloon pump
Emergency or high risk procedures - ruptured AAA, ischemic time, high volume blood transfusion

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23
Q

AKI Preop Tx

A

Replace intravascular fluid deficits

  • Balanced salt solution minimizes ​ADH & renin-angiotensin-aldosterone release
  • Attenuate surgical stress

A-line, TEE, CVP, foley catheter

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24
Q

AKI Periop Tx

A 
*Fluid replacement
Colloids vs. crystalloids
Goal 0.5-1mL/kg/hr
*Improve CO
*Normalize SVR
Avoid diuretics to treat oliguria
Prevention & management
- Prevent prolonged hypotension
- Prophylaxis
- Initial insult duration & severity determines AKI

Admin volume NS to euvolemia
↓afterload ↑CO
Limited renal ischemia duration

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25
Q

Chronic Kidney Disease

A

Renal function ↓10% per decade
GFR < 60mL/min for 3 MONTHS
S/S & abnormal labs do not appear until <40% normal functioning nephrons remain
95% loss renal function → uremia, volume overload, CHF

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26
Q

CKD Systemic Effects

Cardiovascular

A

HTN & CHF
90% volume dependent
10% 2° ↑renin
Pericardial effusion
Ischemic heart disease = most common cause death
Outcomes better w/ CABG than angioplasty
Pericarditis in patients w/ severe anemia

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27
Q

CKD Systemic Effects

Respiratory

A

Respiratory depression 2° delayed clearance

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28
Q

CKD Systemic Effects

Neurologic

A

Fatigue & weakness - early complaints
Autonomic neuropathy
Disequilibrium syndrome → seizures, stupor, & coma

29
Q

CKD Systemic Effects

Hematologic

A

Normochromic, normocytic anemia
↓erythropoietin production
↓erythrocyte life 2° dialysis
Blood loss from frequent sampling

Prolonged bleeding ↓clotting factors
↓platelet function
Dialysis w/in 24hrs corrects
Desmopressin ↑factor VIII levels

RBC transfusion citrate binds to Ca2+ → hypocalcemia

30
Q

CKD Systemic Effects

Gastrointestinal

A

Dialysis patients ↑risk GI bleeding

Mucosal changes & inflammation

31
Q

CKD Systemic Effects

Infection

A

Protein malnutrition

Neutrophil, monocyte, & macrophage changes

32
Q

CKD Systemic Effects

Endocrine

A

Hyperparathyroidism (compensatory mechanism)

Adrenal insufficiency

33
Q

CKD Systemic Effects

Electrolyte

A

Na+ wasting
Hypocalcemia
Hyperkalemia

34
Q

Hyperkalemia

A 
K+ 7-8mEq/L → fatal dysrhythmias
Treatment:
- 25-50g dextrose
- 10-20 units regular insulin
- 50-100mEq sodium bicarbonate
- Hyperventilate ↓CO2
Check preop levels
35
Q

CKD Anesthetic Considerations

Preop

A

Labs & diagnostic tests
Continue antihypertensive medications
Renal insufficiency - preop volume replacement

36
Q

CKD Anesthetic Considerations

Periop

A

A-line
Regional vs. general anesthesia
Central line
Fluid management

37
Q

CKD Anesthetic Considerations

Postop

A

Dialysis w/in 24-36hrs

38
Q

CKD Anesthetic Considerations

Fluid Management

A

UOP 0.5-1mL/kg/hr
Treat mildly compromised function w/ balanced salt solution 3-5mL/kg/hr w/ 500mL bolus PRN
LR & other K+ containing solutions contraindicated when patient UOP <100mL/day
Reserve blood products for patients requiring ↑oxygen-carrying capacity

Renal insufficiency or ESRD
- Replace fluid volume deficit preop
- Intraop losses >15% EBL replace w/ 1:1 colloid
- Crystalloid w/o K+ 2-3mL/kg/hr
Dialysis patient
- Insensible losses replace w/ 5-10mL/kg D5W
- Replace urine produced w/ 0.45% saline

39
Q

Dialysis Physiologic Effects

A

Hypotension
Muscle cramping
Anemia
Nutritional depletion

40
Q

Serum Creatinine

A

0.7-1.5mg/dL

↓GFR 50% → serum creatinine doubles

41
Q

BUN

A

Blood urea nitrogen
10-20mg/dL
BUN:creatinine ratio 10:1

42
Q

Creatinine Clearance

A 
MOST RELIABLE RENAL FUNCTION TEST
95-150mL/min
Measure glomerular ability to excrete creatinine in urine
Mild dysfunction 50-80mL/min
Moderate <25mL/min
<10mL/min requires dialysis
43
Q

Pharmacologic Considerations

A

↓protein binding ↑sensitivity
Morphine not removed by dialysis
Meperidine metabolite Normeperidine not removed by dialysis
H2 blockers dependent on renal excretion ↓dose

44
Q

Regional Anesthesia

A

Well-tolerated
Block DOA not impacted by renal failure
Spinal/epidural - obtain platelet count, PT/PTT, coags

Concerns include intolerance, coagulopathy, peripheral neuropathy, & infection risk

45
Q

General Anesthesia Drugs

A 
IV ↑Vd ↓protein binding
Ketamine & benzos less protein bound
Propofol = safe
Dexmedetomidine hepatic clearance
Remifentanil ↓plasma esterases ↓clearance ESRD patients
46
Q

NMBs

A 
Succinylcholine
- ↑K+ 0.5mEq/L
- Cholinesterase deficiency (uremic patients)
Pancuronium
- 80% renal excretion
Atracurium/Cisatracurium/Mivacurium
- DOA not impacted in renal failure
Vecuronium
- 30% renal excretion
- Effects rapidly reversed w/ dialysis
Rocuronium
- Renal failure ↓clearance 40% → longer DOA
47
Q

Cystoscopy

A 
Any urologic procedure not open
Cystoscope to examine urethra & bladder
Diagnostic or treatment procedures
Position = lithotomy
Void prior to discharge home
48
Q

Extracorporeal Shock Wave Lithotripsy

A

ESWL
Nephrolithiasis (renal calculi or kidney stones)
<5mm pass w/o intervention
5-10mm medical management
>10mm requires intervention
Non-invasive treatment that uses high-energy ultrasound waves to breakup calculi
- Outpatient procedure under GA
- R wave used to trigger shocks (EKG placement)
- Hematuria common

49
Q

ESWL Contraindications

A

Active UTI
Uncorrected bleeding disorder or coagulopathy
Distal obstruction
Pregnancy

50
Q

ESWL Complications

A

Dose-dependent hemorrhagic lesions
Perforation, rupture or damage to colon, hepatic structures, lungs, spleen, pancreas, abdominal aorta, or iliac veins
Hematuria develops in most patients
Diabetes, new-onset HTN, or ↓renal function

51
Q

ESWL Anesthetic Considerations

A

GA rapid onset & able to control patient movement
Spinal/epidural level T4/T6
MAC
Topical LA

Discontinue ASA, anticoagulants, platelet inhibitors, & NSAIDs 7-10 days prior to procedure ↓hematuria risk
Document negative urine culture
HCG on appropriate patients
Laser eye protection

52
Q

Percutaneous Nephrolithotomy

A

Procedure to remove kidney stones <25mm
GA & postop hospitalization (admit inpatient)
Prone or supine position

53
Q

Percutaneous Nephrolithotomy

Complications

A

Pain, fever, UTI, renal colic, septicemia, bleeding, pneumothorax/hemothorax, anaphylaxis

54
Q

TURP

A

Transurethral resection of prostate (BPH)
Most common surgical procedure performed in men >60yo
Scope placed through urethra to cut away obstructing prostate lobes
Bladder distended & continuous irrigation used
ANESTHETIC RISKS R/T PATIENT AGE & ASSOCIATED COMORBIDITIES

55
Q

TURP Anesthetic Considerations

A 
Commonly performed under GA
Spinal anesthesia preferred to assess patient mental status S/S complications more easily detected
PREVENTION most important approach
- Avoid trendelenburg position
- Limit resection <1 hour
- Place irrigation solution <60c, above prostate
- Monitor electrolytes
- Regional technique w/ sedation
56
Q

TURP Irrigation Solutions

A

Distilled water
1° Saline
Cytal (sorbitol & mannitol)
Glycine → toxicity

57
Q

TURP Complications

A 
Volume overload w/ pulmonary edema
Dilutional hyponatremia w/ hypoosmolality → cerebral swelling ↑ICP
Cardiac effects
Renal toxicity (glycine)
Hyperglycemia
Hypothermia
Glycine absorption
Bleeding (difficult to assess d/t irrigation)
Bladder perforation
Infection
Skin burns
TURP syndrome
58
Q

TURP Syndrome

A

Rare but significant complication
Mortality up to 25%
Fluid absorbed through prostate

59
Q

TURP Syndrome S/S

A

Combination water intoxication, fluid overload, & hyponatremia
Water intoxication - confusion, restlessness, seizure, lethargy, coma, dilated sluggish pupils
Fluid overload - HTN, bradycardia, arrhythmia, angina, pulmonary edema, CHF, hypotension
Hyponatremia - CNS changes, widened QRS, T-wave inversion
Glycine toxicity - N/V, headache, transient blindness, myocardial depression

60
Q

TURP fluid absorption dependent on _____

A

Resection size & duration
Irrigation solution pressure
Number venous sinuses open at once
Provider experience

61
Q

TURP Fluid Absorption

A

30mL fluid absorbed per minute
Up to 8L in 2 hours
1L irrigant uptake ↓serum Na+ 5-8mEq/L
Serum Na+ <120mEq/L associated w/ severe reactions

62
Q

Glycine Absorption

A

Glycine - amino acid
Acts as inhibitory transmitter
Excessive absorption → N/V, fixed & dilated pupils, headache, weakness, muscle incoordination, TURP blindness, seizures, hypotension

63
Q

TURP Syndrome Treatment

A 
Early recognition
Notify surgeon to stop surgery
Correct hyponatremia
Furosemide 20mg IV 
Labs - electrolytes, glucose, Hct, creatinine, ABG, 12-lead EKG
Midazolam 1mg PRN seizures
Pulmonary edema → intubate
PRBCs
Investigate DIC or 1° fibrinolysis
64
Q

Hyponatremia Correction

A

3-5% saline <100mL/hr
↑Na+ 0.5mEq/hour or 8mEq/day
Goal Na+ >120mEq/L
Rapid reversal → osmotic demyelination syndrome

65
Q

Laparoscopic Urologic Surgery

Anesthetic Considerations

A

Pneumoperitoneum 15mmHg
Urologic system retroperitoneal (communicates w/ thorax) → risk subcutaneous emphysema
Alterations in renal & hepatic perfusion
CO2 absorption → potential acidosis
↑intraabdominal & intrathoracic pressures
Hemorrhage

66
Q

Robotic Urologic Surgery

A

Upper tract - simple or radical nephrectomy, radical nephroureterectomy, nephron-sparing

Pelvic - radical cystectomy, radical prostatectomy

67
Q

Robotic Urologic

Anesthetic Considerations

A 
Steep trendelenburg
Lithotomy (prostatectomy)
Arms tucked at sides
Airway assessment BEFORE extubation
Duration 3-4 hours
EBL <300mL
Limit fluids until urethra reconnected 2L total
Large bore PIVs & A-line
DVT prophylaxis, eye protection, OG tube, Bair hugger, antibiotics, dexamethasone
Remifentanil infusion common
68
Q

Nephrectomy

A 
Open vs. laparoscopic
Lateral jack-knife position (kidney rest)
Cardiovascular compromise
3rd spacing & edema
Hemodynamic monitoring A-line
Postop pain management
69
Q

Renal Transplant

A

ESRD treatment
Donors living or deceased
Most frequent solid organ transplant today
5-year survival rate 70%
Transplanted kidney placed in R or L extraperitoneal fossa (R preferred)
Attached via vascular anastomoses external iliac artery & vein & ureter anastomosed to bladder
GA with A-line & CVP monitoring
Propofol & Cisatracurium
Immunosuppressant therapy

AS - N931 Advanced Principles of Anesthesia (17 decks)

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