Renal Review* Flashcards
Which common drug used for periop control should be avoided in patients at risk for medullary ischemia?
Toradol (ketorolac)
Renal Failure and Induction Agents:
- No major clinical change? (consider BP drop/CV status)
- Highly PB, free fraction can be 2x normal (exaggerated response)?
- Highly protein bound, longer lasting sedation?
- 60-80% cleared by kidneys in form of active metabolite and highly PB?
- Etomidate, Ketamine, Propofol
- Thiopental
- Precedex
- Midazolam
Opioids and Renal Failure:
- Avoid repeated dosing, active metabolite?, highly PB and histamine release?
- AVOID? metabolite?
- Accumulates avoid repeated dosing? metabolite?
- **These are ok to give!?
- Morphine- 6 glucuronide
- Meperidine- normeperidine
- Hydromorphone- 3 glucuronide
- **Fentanyl, Alfentanil, Remifentanil
- FAR and away the best way to treat pain in RF
RF and Premedication:
- ___ usually not given due to CNS effects
- ___ use short acting and titrate carefully
- ___ alpha blocker, may accentuate hypotension-usually small dose ok
- ___ highly dependent on renal excretion - but do use with GI prophylaxis, ___ will accumulate in RF, avoid this!!
- Scopolamine
- Benzos
- Phenothiazine (droperidol)
- H2 blockers, reglan
Maintenance of RF want to avoid ___ and ___
Halothane = Increased K+ and acidosis leads to myocardial irritability
Enflurane = avoid due to fluoride concern
- Avoid ___ unless you have a good reason (ex: RSI)
- **Maintenance RF - Inhalation Agents:
- Avoid these 2 IAs? Controversial?
- Ideal VAs??
- Careful accelerated induction and emergence seen with ___ d/t decreased solubility
- Succ (check K+ level!)
- Halothane and Enflurane, Sevoflurane
- Desflurane and Isoflurane
- severe anemia
Maintenance of Anesthesia: ??? -If HTN persists ? -Hypoventilation exacerbates \_\_\_ -Hypercapnia predisposes to \_\_\_ -Alkalosis causes ?
- opioid with N2O/O2/agent
- increase IAs, NTG, Hydralazine
- acidosis
- arrhythmias
- left shift on oxy-hgb curve
- **Alkalosis just as bad as acidosis, want a happy equilibrium! :-)
___ - renal excretion is primary route of elimination thus will see a prolonged 1/2 life of these drugs
- Percentage of Renal Excretion
- edrophonium - ___ renally excreted
- neostigmine - ___
- pyridostigmine - ___
Reversal Agents
- 75%
- 50%
- 75%
Fluid Management:
Very narrow margin for anuric patients with CHF.
Patient tipping into CHF give ___ - but give very judiciously!!! Usually give 1 mg then another, tend to not go above 5 mg - any higher and could tip patient into hypovolemia. Patient in OR at risk for bleeding, evaporation (third space loss) = losing lots of fluids in OR why you use very low end dosing. ***___ can be given when UOP decreases
lasix
lasix 5 mg
Regional Anesthesia:
- Shunt placement?
- Mental status altered?
- Seizure threshold decreased with ?
- Brachial plexus block/sedation + local
- Uremic encephalopathy
- Metabolic acidosis
- **Overall goal = Adequate Intravascular Fluid Volume and minimizing CV Depression - Vasopressors are used sparingly:
- Results in greatest interference with renal circulation?
- Don’t result in renal vasoconstriction but increase myocardial irritability?
- Phenylephrine (alpha adrenergic agonist)
- Beta adrenergic
Cystoscopy:
- Patient will be placed in ___ position
- potential nerve injuries (5)
- decreased ___ with resulting ___
- Increased ___ exacerbating ___
- Lithotomy
- common peroneal, saphenous, sciatic, femoral, obturator
- FRC, atelectasis
- Venous return, CHF
Cystoscopy: -With GA use? -With Regional: ~\_\_\_ longer to set in so \_\_\_ preferred ~sensory level block at \_\_\_ ~does not abolish \_\_\_ (can be stimulated with electrocautery - will see \_\_\_ rotation and \_\_\_ of the thigh) = Blocked ONLY by \_\_\_
-LMA ~Epidural, Spinal ~T10 ~obturator reflex -external rotation and adduction of the thigh -muscle paralysis
***Prevention of TURP Syndrome:
Cause = systemic absorption of irrigating fluids via venous sinuses
-Limit irrigating fluid height to ___ above prostate
-Limit resection time to less than ___
*s/s = HA, restless, confusion, cyanosis, dyspnea, hypotension with bradycardia, arrhythmias, seizures
*___ not used because they disperse electrocautery current
- 40 cm
- one hour
- electrolyte solutions
Treatment of TURP Syndrome: *Key is ?
-fluid restriction -diuretic type ?
-If hyponatremia present - ___ solution (___ mL of ___ over ___ hours) administered based on patients serum sodium (ideally greater than __)
-Treat seizures with (3)
~if glycine used consider a trial of ___
-Intubate
- Early Recognition
- loop
- hypertonic solution
- 100 mL of 3% NS over 1-2 hours
- 120
- TPL, phenytoin, versed
- magnesium
