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N931 Advanced Principles of Anesthesia I > urologic surgery > Flashcards

urologic surgery Flashcards

1
Q

a testicular torsion is an

A

emergency

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2
Q

the kidneys receive how much cardiac output

A

20-25%

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3
Q

the nephron is made up of the

A

outer cortex and inner medulla

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4
Q

the nephron maintains homeostasis via

A

filtration, reabsorption and tubular excretion

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5
Q

normal GFR

A

125 mL/min

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6
Q

the outer cortex contains the

A

glomerulus

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7
Q

what shouldn’t you see in the urine?

A

glucose and protein

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8
Q

dilation of afferent arteriole ___ GFR

A

increases

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9
Q

constriction of afferent arteriole ____ GFR

A

decreases

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10
Q

what is the strongest trigger in releasing aldosterone to reabsorb sodium and water

A

K+

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11
Q

filtration is the 1st process in

A

making urine

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12
Q

the renal vasculature is richly innervated by

A

SNS

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13
Q

renal hormones

A

aldosterone, antidiuretic hormone, angiotensin, atrial naturetic factor, vitamin D, prostaglandins

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14
Q

filtration happens in the

A

bowman’s capsule

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15
Q

what is filtered in the bowman’s capsule

A

water, glucose, electrolytes, amino acids, urea, creatinine

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16
Q

where does reabsorption occur

A

proximal and distal tubules

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17
Q

what is reabsorbed in the proximal tubule

A

glucose, k+, urate, HCO3

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18
Q

what is reabsorbed in the distal tubule

A

Na+ and H2O

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19
Q

anesthetic drug effects on renal function

A

depresses normal renal function
renal blood flow decreases by 30-40%
impairs autoregulation

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20
Q

general anesthesia is associated with a decrease in

A

renal blood flow
GFR
urinary flow
electrolyte secretion

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21
Q

ALL of the volatile anesthestics cause ____ in renal vascular resistance

A

a mild increase d/t compensatory mechanism in response to decreases in CO and SVR

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22
Q

What can attenuate reductions in renal blood flow and GFR?

A

preop hydration
decreased concentrations of volatile anesthetics
maintenance of blood pressure

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23
Q

Sevoflurane can cause ____ but NOT ____

A

high fluoride ion levels but NOT nephrotoxicity d/t rapid metabolism

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24
Q

When Sevoflurane is degraded by absorbents is produces

A

compound A or vinyl ether

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25
Q

how do you decrease risk of compound A nephrotoxicity with someone receiving sevoflurane?

A

high gas flows (1L/min FGF for 2 MAC hours max)
decrease gas concentration
use of carbon dioxide absorbents

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26
Q

at 1 L/min of FGF Sevoflurane 2% =

A

2 MAC hours

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27
Q

at 1 L/min of FGF Sevoflurane 1% =

A

4 MAC hours

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28
Q

at 1 L/min of FGF Sevoflurane 4% =

A

1 MAC hour

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29
Q

Fluoride ion toxicity

A

fluoride interferes with active transport of sodium and chloride in the loop of Henle

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30
Q

Fluoride is a ___ vaso___

A

potent vasoconstrictor

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31
Q

nephrotoxicity from fluoride ions causes

A

proximal tubular swelling and necrosis

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32
Q

signs and symptoms of fluoride nephrotoxicity

A 
polyuria
hypernatremia
serum hyperosmolality
elevated BUN/creat
decreased creatinine clearance
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33
Q

nephrotoxicity is related to

A

dosage, duration, and peak fluoride concentrations

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34
Q

Fluoride can inhibit

A

many enzyme systems including ADH

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35
Q

Acute kidney injury

A

renal functional or structural abnormality that occurs within 48 hours
increased creatinine 0.3 mg/dL or 50% increase
UO <0.5 mL/kg/hr x 6 hours

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36
Q

risk of AKI is increased by

A

hypovolemia, electrolyte imbalance, and contrast dye

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37
Q

pre-renal AKI causes

A

hypoperfusion without parenchymal damage from hemorrhage, vomiting, diarrhea, diuretics, sepsis, shock, CHF, norepi, NSAIDs, ACEi

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38
Q

Intrinsic AKI causes

A

result of damage to renal tissue from hypoperfusion, myoglobin, chemotherapy, infections, lymphoma, toxemia of pregnancy, vasculitis

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39
Q

postrenal AKI causes

A

due to urinary tract obstruction from renal calculi, peritoneal mass, prostate/bladder urethra tumor, fibrosis, hematoma, strictures

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40
Q

risk factors for AKI

A

aging >50, preop renal dysfunction, cardiac or hepatic failure, cardiac bypass, aortic cross clamp, arteriography, intra-aortic balloon pump, ruptured AAA, ischemic time, large volume of blood transfusion

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41
Q

anuric

A

<100 mL/day

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42
Q

polyuric

A

> 2.5 L/day

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43
Q

oliguric

A

<400 mL/day

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44
Q

what kind of clamp do we want with AAA?

A

infrarenal

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45
Q

AKI preop treatment

A

balanced salt solution with minimize ADH and RAA release, attentuation of surgical stress

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46
Q

fluid replacement for periop AKI treatment

A

500-1000mL bolus for hourly urine output below acceptable levels
high risk patients: 0.5-1 mL/kg/hr

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47
Q

AKI perioperative treatment

A

fluid replacement
improve cardiac output
normalize systemic vascular resistance

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48
Q

diuretic use is

A

not recommended to prevent oliguria

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49
Q

early treatment of ___ causes has best outcomes

A

pre-renal AKI

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50
Q

which AKI is most difficult to treat?

A

intra-renal AKI

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51
Q

most common cause of AKI is

A

prolonged hypoperfusion

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52
Q

___ reduces mortality more than dialysis

A

prophylaxis

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53
Q

key strategy for AKI perioperative treatment

A

limiting magnitude and duration of renal ischemia

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54
Q

renal function decreases by ____ per decade

A

10%

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55
Q

CKD exists when GFR is

A

< 60 mL/min/1.73 m2 for 3 months

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56
Q

signs and abnormal labs do not appear until less than ___ of normal functioning nephrons remain

A

40%

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57
Q

when someone has 95% loss of renal function

A

uremia, volume overload, CHF

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58
Q

uremia

A

high uric acid, basically urine is floating in the blood and will need dialysis

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59
Q

stage I of CKD

A

kidney damage with normal GFR

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60
Q

stage II of CKD

A

GFR 60-89 mL/min/1.73 m2 with kidney damage

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61
Q

stage III of CKD

A

GFR 30-59 mL/min/1.73 m2

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62
Q

stage IV of CKD

A

GFR 15-29 mL/min/1.73 m2

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63
Q

Stage V of CKD

A

GFR < 15 mL/min/1.73 m2 with end stage failure

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64
Q

systemic effects of CKD

A

hypertension and congestive heart failure* (90% volume dependent, 10% secondary to increased renin), pericardial effusion, pericarditis, anemia, respiratory depression, fatigue, weakness, autonomic neuropathy

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65
Q

most common cause of death with CKD

A

ischemic heart disease

66
Q

autonomic neuropathy can lead to

A

delayed gastric emptying

67
Q

disequilibrium syndrome from dialysis

A

decreased Na+ = rapid increased cerebral edema, stupor, coma, CNS effects, seizures

68
Q

hematologic effects from CKD

A

normochromic, normocytic anemia, decrease in erythropoietin, reduction in erythrocyte life secondary to dialysis, blood loss from frequent sampling, prolonged bleeding, decrease in platelet function

69
Q

desmopressin (DDAVP) increases levels of

A

factor VIII

70
Q

dialysis patients are at greater risk for ___

A

GI bleeding

71
Q

endocrine and electrolyte changes from CKD

A 
hyperparathyroidism
adrenal insufficiency
sodium wasting
hypocalcemia
hyperkalemia
72
Q

mucosal changes can happen with CKD d/t ___ and considerations

A

inflammation; risk for GI bleed, consider H2 blockers or antacid, infection common

73
Q

Hyperkalemia is a serious disturbance in patients with

A

renal disease

74
Q

fatal dysrhythmias or cardiac standstill can occur when K+ levels reach

A

7-8 mEq/L

75
Q

treatment for hyperkalemia

A

25-50 grams dextrose
10-20 units of regular insulin
50-100 mEq of sodium bicarbonate
hyperventilate (decreases K+ by 0.5 mEq)

76
Q

physiologic effects of dialysis

A

hypotension, muscle cramping, anemia, nutritional depletion

77
Q

hyperkalemia on ECG

A

peaked T waves then widen PR interval then sinusoidal wave

78
Q

CaCl should be given

A

through a central line, slowly

79
Q

Calcium Gluconate can be given

A

peripherally, slowly

80
Q

fluid management

A

urine output 0.5-1 mL/kg/hr

balanced salt solution 3-5mL/kg/hr with 500 mL bolus prn

81
Q

what fluids are contraindicated in anuric patients

A

potassium containing solutions (LR)

82
Q

intra-operative losses greater than ___ should be replaced with colloid 1:1

A

15%

83
Q

how much K+ is in LR?

A

4 mEq

84
Q

how much crystalloid without potassium should be given in renal insufficient patients?

A

2-3mL/kg/hr

85
Q

insensible loss replacement in dialysis patients

A

5-10 mL/kg of D5w

86
Q

if dialysis patients produce urine what solution would you use for insensible losses

A

0.45% saline

87
Q

for every 50% reduction in GFR, serum creatinine ___

A

doubles

88
Q

BUN:creatinine ratio is

A

10:1

89
Q

BUN can be effected by

A

liver disease, excise, and keto diet

90
Q

most reliable test for renal function

A

creatinine clearance

91
Q

creatinine clearance measures

A

glomerular ability to excrete creatinine in urine

92
Q

mild renal dysfunction creatinine clearance

A

50-80 mL/min

93
Q

moderate renal dysfunction creatinine clearance

A

<25 mL/min

94
Q

a creatinine clearance less than ____ requires dialysis

A

10

95
Q

reduced protein binding may result in

A

increased sensitivity to drugs

96
Q

which opioids are NOT removed by dialysis

A

morphine and meperidine metabolite

97
Q

H2 blockers are highly dependent on

A

renal excretion

98
Q

regional anesthesia in CKD is

A

well tolerated

99
Q

major concerns for regional anesthesia in CKD patients

A

intolerance, coagulopathy, peripheral neuropathy, risk of infection

100
Q

intravenous drugs in CKD patients

A

Vd is increased
decreased protein binding
low pH
renal excretion

101
Q

which agents that we give frequently has less protein binding and don’t need to be renally adjusted as much?

A

ketamine and benzos

102
Q

is dexmeditomidine ok to use in renal patients?

A

yes, cleared by the liver

103
Q

remifentanil has ____ clearance in patients with ESRD

A

reduced d/t decreased plasma esterases

104
Q

Succinylcholine and renal disease

A

increases serum potassium 0.5 mEq/L
succinylmonocholine is renally excreted
uremic patients have cholinesterase deficiency

105
Q

pancuronium and renal disease

A

AVOID IT

80% renally excreted

106
Q

atracurium, cisatracurium, and mivacurium and renal disease

A

duration NOT increased in renal failure

slower onset with cisatracurium and mivacurium

107
Q

vecuronium and renal disease

A

30% excreted via renal system

effects rapidly reversed with dialysis

108
Q

rocuronium and renal disease

A

renal failure reduces clearance by almost 40%

longer DOA

109
Q

patients with ESRD generally require dialysis ____ after major surgery

A

24-36 hours

110
Q

uremic patients may require replacement with

A

RBCs, FFP, colloids

111
Q

common urologic procedures

A

cystoscopy, extra-corporeal shock wave lithotripsy, transurethral resection of the prostate, lap/robotic urologic procedures, open nephrectomy, renal transplant

112
Q

cystoscopy

A

urologist uses a cystoscope to examine the urethra and bladder
can be diagnostic or intervention
cystoscope can be rigid or flexible

113
Q

cystoscopy positioning

A

lithotomy

risk for peroneal nerve injury

114
Q

ESWL (extra-corporeal shock wave lithotripsy)

A

non-invasive treatment that uses high energy US waves to break up the calculi
outpatient under GA
hematuria is common
need ECG - R wave is used to trigger shocks

115
Q

if there are kidney stones in the distal ureter

A

they need to be surgically removed

116
Q

kidney stones aka ___ affect ___ of the population

A

nephrolithiasis, renal calculi, affect 9%

made up of calcium

117
Q

if calculi less than 5mm in diameter

A

expected to pass without intervention

118
Q

if kidney stone 5-10 mm

A

medical management

119
Q

if kidney stone >10 mm

A

unlikely to pass spontaneously

120
Q

contraindications of ESWL

A

active UTI
uncorrected bleeding disorder or coagulopathy
distal obstruction
pregnancy

121
Q

complications of ESWL

A

dose-dependent hemorrhagic lesions on kidneys
perforation, rupture, damage to colon, hepatic structures, lungs, spleen, pancreas, abdominal aorta or iliac veins
hematuria
diabetes, new-onset HTN, decreased renal function

122
Q

most common complication with ESWL

A

hematuria

123
Q

if ESWL fails

A

IR under fluoroscopy

124
Q

if you do a spinal/epidural for a patient getting an ESWL what level do you want it to reach

A

T4/T6 level

125
Q

anesthetic considerations for ESWL

A

discontinue ASA, anticoagulants, platelet inhibitors, NSAIDs 7-10 days prior to procedure
need negative urine culture
HCG if of child bearing age
laser eye protection for us and the patient

126
Q

percutaneous nephrolithotomy

A

procedure to remove kidney stones 25 mm or smaller
usually a secondary surgery option if other fails
done under GA
rigid scope inserted in renal calyx under fluoroscopy
in prone or supine position

127
Q

complications of percutaneous nephrolithotomy

A

pain, fever, UTI, renal colic, septicemia, bleeding, pneumothorax, hemothorax, anaphylaxis

128
Q

TURP

A

scope placed through urethra to cut away obstructing lobes of the prostate
the bladder is distended and continuous irrigation is used
commonly done under GA

129
Q

medical management used for BPH

A

alpha blocking agents - flomax/tamsulosin

130
Q

what is the most common surgical procedure in men over 60

A

TURP

131
Q

anesthetic risks with TURP are related to

A

the patient’s age and associated comorbidities, not the procedure itself

132
Q

anesthetic of choice for TURP

A

spinal anesthesia, d/t being able to detect complications

133
Q

TURP syndrome!

A

rare but significant!
mortality as high as 25%
large amounts of fluid absorbed through the prostate
can happen within 24 hours of the procedure

134
Q

TURP syndrome hallmark symptoms

A

fluid overload, water intoxication, hyponatremia, glycine toxicity

135
Q

fluid overload in TURP syndrome

A

HTN, bradycardia, arrhythmia, angina, pulmonary edema, CHF, hypotension

136
Q

water intoxication in TURP syndrome

A

confusion, restlessness, seizure, lethargy, coma, dilated sluggish pupils

137
Q

hyponatremia in TURP syndrome

A

CNS changes, widened QRS, T wave inversion

138
Q

glycine toxicity in TURP syndrome

A

NV, HA, transient blindness, myocardial depression

139
Q

spinal block for TURP

A

up to T10

140
Q

complications of TURP

A

volume overload w/ pulm edema, dilutional hyponatremia w/ hypoosmolality, cardiac effects, renal toxicity, hyperglycemia, hypothermia

less common: glycine absorption, bleeding, infection, bladder perf, skin burns

141
Q

Na+ 120 will see

A

EKG changes

142
Q

Na+ 115 will see

A

wide QRS

143
Q

Na+ 100 will see

A

vfib/vtach

144
Q

which cutting device has greater incidence of causing skin burns during TURP

A

MONOpolar

145
Q

fluid absorption during TURP is dependent on

A

size of resection, duration of resection, irrigation solution pressure, number of venous sinuses open at a time, provider experience

146
Q

up to ___ of fluid is absorbed per minute in TURP

A

30 mL

up to 8 L in 2 hours

147
Q

uptake of 1L of irrigant can decrease serum Na+ by

A

5-8 mEq/L

148
Q

glycine is an amino acid that

A

acts as an inhibitory transmitter

149
Q

excessive absorption of glycine can lead to

A

NV, fixed and dilated pupils, HA, weakness, muscle incoordination, TURP blindness, seizures, hypotension

150
Q

TURP considerations

A

avoid Trendelenburg position!
limit resection to less than one hour
place irrigating solution less than 60 cm above prostate
monitor electrolytes
use a regional technique with light sedation

151
Q

treatment for TURP syndrome

A

correct hyponatremia: 3-5% saline no greater than 100mL/hr
20 mg IV lasix
1 mg IV versed
PRBCs
intubate
investigate for DIC or primary fibrinolysis

152
Q

increase sodium by ___ / hour or ___ /day in TURP syndrome

A

0.5 mEq; 8 mEq

153
Q

Sodium goal in TURP syndrome

A

greater than 120 mEq/L

154
Q

rapid reversal of hyopnatremia can result in

A

osmotic demyelination syndrome

155
Q

laparoscopic urologic surgery anesthetic considerations

A 
pneumoperitoneum 
subcutaneous emphysema
alterations in perfusion
CO2 absorption potential of acidosis
increased intrabdominal and intrathoracic pressures
hemorrhage
156
Q

upper tract robotic urologic surgeries

A

simple or radical nephrectomy, radical nephroureterectomy, nephron sparing surgery

157
Q

pelvic robotic urologic surgeries

A

radical cystectomy, radical prostatectomy

158
Q

robotic urologic surgery considerations

A 
steep trendelenburg (+ lithotomy for prostatectomy), arms tucked, lasts 3-4 hours, do an airway assessment before extubation, EBL < 300mL, limit fluids until urethra is reconnected, large bore IV
DVT prophylaxis, eye protection, OGT, bair hugger, antibiotics, dexamethasone, remifentanil
159
Q

nephrectomy

A

can be open or laparoscopic

removing total or partial kidney

160
Q

anesthetic considerations for nephrectomy

A 
lateral jack knife position
CV compromise
third spacing and edema
hemodynamic monitoring
postop pain management 
check pressure points
161
Q

renal transplant

A

mainstay treatment for end stage renal disease
donors may be living or deceased
most frequent solid organ transplanted today
5 year survival rate is 70%

N931 Advanced Principles of Anesthesia I (6 decks)

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