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6901 > 6901 Renal > Flashcards

6901 Renal Flashcards

1
Q

Why does kidney’s location make it likely to have occult bleeding?

A

if in peritoneum will not see bleeding bc kidneys are located retroperitoneally

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2
Q

Kidneys and all blood vessels are embedded in what? and Enclosed in what?

A

embedded in perirenal fat and enclosed in renal fascia

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3
Q

What holds kidneys in place during movement?

A

large vessels and fascia

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4
Q

When do you know the surgeon is close to closing in partial nephrectomy?

A

when brings perirenal fat over operated part of kidney you know they’re ab to close the fascia

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5
Q

Kidneys extend from what thoracic vertebrae to what?

A

12th thoracic vertebrae to 3rd lumbar vertebrae

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6
Q

Which kidney is lower and why?

A

right; d/t liver

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7
Q

3 regions of kidney?

A

cortex, outer medulla, inner medulla

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8
Q

Major site for urine collection and is connected to bladder via ureters?

A

renal pelvis

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9
Q

Spleen sits right on top of which kidney?

A

left

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10
Q

Blood supply for kidneys emerges from?

A

aorta and drain that goes right from renal vein directly in to IVC

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11
Q

What are the pyramids and where are they located?

A

medulla; they are triangular wedges. base of each pyramid is directed toward renal cortex. apexes converge towards renal pelvis

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12
Q

Why do pyramids have striated appearance?

A

contain loop of henle and collecting ducts of nephron

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13
Q

What is the apex of each pyramid called and what is it composed of?

A

papilla: composed of many collecting ductsand those papillary ducts empty in to cup shaped structure down as minor calyx

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14
Q

Relationship among minor calyx, major calyx, and renal pelvis?

A

minor calyces join to form major calcyes, which come together as renal pelvis

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15
Q

What is the major reservoir for urine?

A

renal pelvis

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16
Q

What structure connects the renal pelvis to the bladder?

A

ureters

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17
Q

Where is the vesicoureteral sphincter? And how is it activated?

A

in ureter at end of calyces; opens when urine enters bladder and presses on it

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18
Q

4 functions of renal system?

A
  1. acid base 2. regulation of body fluid volume and composition 3. detox and excretion of nonessential materials including drugs 4. secretion of hormones
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19
Q

6 hormones renal system secretes?

A

ADH, angiotension, aldosterone, ANF, vit D, erythropoietin

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20
Q

2 types of nephrons and which ones play important role in concentration of urine?

A

cortical and juxtamedullary; juxtamedullary

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21
Q

This structure holds the filtrate which has been filtered from the blood?

A

nephron

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22
Q

Where does nephron begin and end?

A

begins in cortex at glomerulus and ends where tubule joins collecting duct at papilla

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23
Q

What is the glomerulus?

A

tuft of capillaries derived from afferent arteriole

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24
Q

Blood is brought to the glomerulus by which arteriole?

A

afferent

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25
Q

Most nephrons are what kind?

A

cortical

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26
Q

Blood that is not filtered returns to the circulation by way of the? What kind of filtration rate does that have?

A

efferent arteriole; very high filtration rate

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27
Q

Flow of the filtrate by which structure it passes thru?

A

glomeruli enters Bowman’s capsule then proximal convoluted tubule then loop of henle, distal convoluted tubule, and collecting duct

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28
Q

The cortex contains what 4 parts of the nephron?

A

glomerulus, Bowman’s capsule, proximal convoluted tubule, and distal tubules

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29
Q

Difference between cortical and juxtamedullary nephrons?

A

cortical extends only partially in to medulla and juxtamedullary lies deep in the cortex and extends to the medulla

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30
Q

How many of the nephrons are juxtamedullary?

A

1/5-1/3

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31
Q

What’s the size of the descending loop of henle and the ascending loop of henle?

A

descending is thin; ascending is thick

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32
Q

Kidneys receive what % of CO?

A

20-25%

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33
Q

Kidney is the only organ where oxygen consumption is determined by?

A

blood flow

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34
Q

Afferent arterioles form what?

A

high pressure capillary bed called the glomerulus

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35
Q

Blood from the glomerulus is drained via the?

A

efferent arteriole

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36
Q

Renal artery is also known as?

A

lobar artery

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37
Q

What does the lobar artery divide in to?

A

interlobar arteries which make arches over pyramids and form arcuate arteries which divide into interlobar arteries which terminate at the afferent arteriole

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38
Q

Efferent arteriole divides in to what which winds around what?

A

peritbular capillary which winds around proximal and distal tubules

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39
Q

Where is it that the peritubular capillaries make the vasa recta?

A

loop of henle

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40
Q

vasa recta is also known as?

A

medullary capillary network

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41
Q

Which arteries supply blood to the pyramids?

A

interlobar arteries

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42
Q

What happens to the GFR and afferent arteriole when renal blood flow decreases?

A

GFR is reduced; vasodilation of afferent arteriole in order to increase GFR

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43
Q

What does the efferent arteriole do to help increase GFR?

A

vasoconstriction

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44
Q

Formula for renal blood flow?

A

(MAP- VP) x VR

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45
Q

Renal blood flow is autoregulated between a MAP of what?

A

75-160

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46
Q

Which arteriole keeps the GFR constant within MAP limits?

A

afferent

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47
Q

Outside the autoregulation limits RBF becomes dependent on?

A

pressure

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48
Q

GFR ceases when systemic arterial pressure is less than?

A

60

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49
Q

6 mechanisms of renal blood flow?

A

intrinsic, tubular glomerular feedback, hormonal, neuronal, SNS, PNS

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50
Q

What is the intrinsic regulation of RBF?

A

myogenic (stretch) response of afferent arteriole

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51
Q

What is the tubular glomerular feedback that regulates RBF?

A

increase in tubular flow rates decreases GFR and vice versa. macula densa is responsible

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52
Q

What are the hormones that help regulate renal blood flow?

A

renin-angiotensin, prostaglandins, ANP

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53
Q

How do prostaglandins provide renal protection?

A

by vasodilating during hypotension

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54
Q

What does ANP do?

A

decreases amt of renin released in response to increased atria volumes

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55
Q

How does SNS innervate afferent and efferent arteriole?

A

vasoconstricts which decreases RBF

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56
Q

When does SNS innervation override autoregulation?

A

when there is SIGNIFICANT SNS stimulation

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57
Q

What does PNS do for renal regulation of blood flow?

A

not significant, not much

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58
Q

Most important index of intrinsic renal function?

A

GFR

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59
Q

Normal GFR in males?

A

125 mL/min

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60
Q

What is the definition of GFR?

A

the quantity of glomerular filtrate formed each minute in all nephrons

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61
Q

First step in formation of urine?

A

filtration

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62
Q

What is the filtration fraction?

A

19%

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63
Q

What % of the protein free filtrate made is reabsorbed?

A

99%

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64
Q

Regulation of GFR is dependent upon what 3 physiologic factors?

A

pressure inside glomerular capillaries, pressure in Bowman’s Capsule, colloid oncotic pressure of proteins

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65
Q

This step of urine formation results from pressures that force fluids and solutes thru the glomerulus?

A

filtration

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66
Q

What type of pressure is inside the glomerulus?

A

high pressure outward force

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67
Q

What type of pressure is colloid osmotic pressure?

A

inward force that holds fluid w/in glomerulus

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68
Q

What does pressure in Bowman’s Capsule do?

A

opposes filtration

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69
Q

Average pressures of glomerular, colloid, and Bowman’s Capsule?

A

60; 28; 18

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70
Q

What is the pressure called that forces fluid thru the glomerular membrane?

A

filtration pressure

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71
Q

Filtration pressure is calculated by?

A

hydrostatic glomerular pressure - (glomerular colloid osmotic + glomerular filtrate pressure)

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72
Q

Normal filtration pressure is?

A

10

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73
Q

3 things which increase GFR?

A

dilation of afferent, increased resistance in efferent, increased RBF

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74
Q

2 ways to decrease GFR?

A

afferent constriction and efferent dilation

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75
Q

What structure regulates the GFR?

A

juxtaglomerular complex

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76
Q

Which part of nephron lies between afferent and efferent arterioles?

A

distal convoluted tubule

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77
Q

Where are macula densa located?

A

they’re dense cells of the distal tubule which come in contact with arterioles

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78
Q

Where is renin contained in kidney?

A

in the juxtaglomerular cells of the smooth muscle cells of afferent and efferent arterioles

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79
Q

Fluid in which tubule alters afferent and efferent flow?

A

distal

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80
Q

Decreased GFR does what to the ions?

A

overabsorption of Na and Cl in ascending limb of LOH and thus a reduction in delivery of these to macula densa

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81
Q

Decreased concentration of Na and Cl cause which arteriole to dilate?

A

afferent so GFR is increased

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82
Q

What causes JG cells to release renin?

A

sympathetic stimulation and decreased delivery of Na and Cl to macula densa

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83
Q

Explain the RAAS process?

A

renin clears angiotensinogen from liver to form angiotensin I which is changed to angiotensin II under influence of ACE

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84
Q

What effects does angiotensin II have?

A

vasoconstriction, efferent arteriole vasoconstriction, which causes pressure in glomerulus to increase and GFR to return to normal

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85
Q

6 segments in the nephron?

A

glomerular capillaries, proximal convoluted tubule, LOH, distal renal tubule, collecting tubule, juxtaglomerular apparatus

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86
Q

This provides a large surface area for filtration of blood?

A

glomerular capillaries

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87
Q

Permeability at the glomerulus is > than that at the capillaries?

A

100-500 fold greater than that of the capillaries

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88
Q

How is ultra filtrate formed in glomerular capillaries different from plasma?

A

doesn’t contain proteins

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89
Q

Tufts of capillaries that join in to Bowman’s Capsule?

A

glomerular capillaries

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90
Q

What pressure causes filtrate to be excreted in to Bowman’s Capsule?

A

hydrostatic pressure from BP

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91
Q

What is active transport?

A

net movement of particles across a membrane against an electrochemical gradient

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92
Q

What is passive transport and what does it rely on?

A

Movement of substances across membranes and relies on concentration gradients or chemical gradients

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93
Q

Difference between primary and secondary active transport?

A

primary requires energy and 2ndary does not

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94
Q

Most primary active transport is for what?

A

Na

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95
Q

2ndary active transport occurs as the result of?

A

movement of Na from tubular lumen to interior of cell

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96
Q

What is co transport?

A

when carrier protein combines with Na and glucose for example

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97
Q

What is counter transport? And a common example?

A

when some molecules are actively secreted into the tubule in exchange for other molecules; H and K secreted in exchange for Na

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98
Q

What is passive transport and how is it created?

A

movement down a concentration or electrical gradient; when substances are actively transported from the tubule to peritbular capillary bed, a concentration gradient that causes passive absorption of water by osmosis is established

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99
Q

Major function of proximal tubule? So what type of channels are the main ones there?

A

Na reabsorption by active transport; Na/K

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100
Q

What enhances Na reabsorption in the proximal tubule?

A

angiotensin and norepi

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101
Q

The osmotic force generated by active Na transport promotes what in the proximal tubule?

A

passive diffusion of water

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102
Q

The short loops and the long loops of the LOH are called?

A

short: cortical; long: juxtamedullary

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103
Q

What is the LOH responsible for?

A

establishing a hyperosmotic state which is vital for the conservation of water

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104
Q

What does a longer LOH mean?

A

a greater concentration gradient

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105
Q

This segment of the LOH has a powerful role in renal mechanisms for diluting or concentrating the urine

A

thick

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106
Q

What controls Na reabsorption in distal tubule?

A

influence of aldosterone

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107
Q

ECF K is controlled how? Does it require energy?

A

in the distal tubule K is secreted in the lumen in exchange for Na; yes to energy

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108
Q

The distal tubule is only permeable to water under the presence of?

A

ADH

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109
Q

This area of the nephron plays a role in the final degree of urine acidification and acid base balance? How?

A

distal tubule; secretes H against concentration gradient (requires energy)

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110
Q

The late distal tubule reabsorbs what % of filtered water?

A

10

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111
Q

This part of the nephron is responsible for acidifying urine? And why?

A

collecting tubule; it can secrete H

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112
Q

In what part of the nephron does aldosterone/Na reabsorption occur?

A

collecting tubule

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113
Q

The permeability of water in the collecting tubule is entirely dependent on?

A

ADH

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114
Q

When does ADH production decrease and increase?

A

increases w dehydration; decreases w adequate hydration

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115
Q

Juxtaglomerular cells are innervated by what?

A

SNS

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116
Q

Cells of the distal tubule come in to contact w arterioles called?

A

macula densa

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117
Q

Where are the juxtaglomerular cells located?

A

afferent and efferent arterioles

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118
Q

Juxtaglomerular cells contain which enzyme?

A

renin

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119
Q

Decreased GFR causes what to happen to Na and Cl? And how does that concern macula densa?

A

over absorption of Na and Cl; results in decreased delivery to macula densa

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120
Q

Decrease in Na and Cl concentrations causes the afferent arteriole to do what and what happens to GFR?

A

afferent arteriole to vasodilate and increase RBF

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121
Q

5 effects angiotensin II has?

A

increased SNS activity, increased tubular Na/Cl reabsorption (H20 retention) and K secretion, aldosterone secretion, arteriolar vasoconstriction and increase in BP, ADH secretion from pituitary gland (collecting duct increases H2O absorption)

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122
Q

100% filtrate produced where?

A

Bowman’s Capsule

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123
Q

What happens in proximal tubule?

A

80% filtrate reabsorbed and passive and active absorption

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124
Q

What happens in LOH?

A

6% of filtrate reabsorbed; H2O and Na conservation

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125
Q

What happens in distal tubule?

A

9% filtrate reabsorbed; variable reabsorption and active secretion

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126
Q

What happens in collecting duct?

A

4% filtrate reabsorbed; variable Na and H2O reabsorption

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127
Q

The chief mineralcorticoid produced by adrenal cortex?

A

aldosterone

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128
Q

What 3 things regulate aldosterone secretion and which is the strongest trigger*?

A

K concentration in ECF*, renin-angiotensin, ECF Na concen

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129
Q

The target site of aldosterone is?

A

the distal nephron

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130
Q

What is the primary effect of aldosterone?

A

increases Na and H2O reabsorption

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131
Q

Where is ADH synthesized and released?

A

synthesized in hypothalamus; released in posterior pituitary

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132
Q

ADH is inhibited by?

A

stretch in atrial baroreceptors

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133
Q

What is a stimulus for ADH secretion?

A

osmoreceptors near hypothalamus sense ECF concentration… and water is reabsorbed d/t ADH

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134
Q

Which 2 parts of the nephron are impermeable to water unless ADH is present?

A

distal tubule and collecting ducts

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135
Q

Hormone that plays a role in countercurrent mechanism?

A

ADH

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136
Q

When a concentration gradient causes fluid to be exchanged across parallel pathways?

A

countercurrent mechanism

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137
Q

What happens in a countercurrent exchanger? And what is the countercurrent exchanger in the kidney?

A

reversal of flow in one stream results in formation of a gradient that allows water and solutes to be exchanged along the length of the tube; descending and ascending LOH

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138
Q

The concentration gradient in the kidney increases from what to what?

A

cortex to medulla

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139
Q

What structure helps maintain the concentration gradient that increases from the cortex to the medulla?

A

vasa recta

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140
Q

Daily urine output?

A

1.5L/day

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141
Q

Approx how much of tubular fluid is reabsorbed from the glomerulus to the proximal tubule?

A

2/3

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142
Q

Osmolarity of urine varies from?

A

40-1400

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143
Q

Tonicity of the filtrate in the glomerulus is the same as?

A

the surrounding tissue

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144
Q

Changes in what part of the LOH are responsible for hypertonicity?

A

thick ascending

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145
Q

This part of the LOH is responsible for active transport of Na and Cl in to medullary interstitium?

A

thick ascending

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146
Q

The tonicity of the descending LOH is?

A

in equilibrium with that of the interstitium

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147
Q

Which part of LOH has low permeability to water?

A

ascending

148
Q

This limb of the LOH is highly permeable to water but does not actively transport Na and Cl?

A

descending

149
Q

Hyperosmotic interstitium causes water to passively move out of what part of LOH?

A

descending

150
Q

Filtrate in descending tubule of LOH is concentrated to?

A

1200

151
Q

What creates hypoosmotic fluid in ascending LOH?

A

active transport of Na and Cl and retention of water

152
Q

Final adjustments of urine volume and concentration take place where?

A

collecting duct

153
Q

How is it that the sluggish blood flow of the vasa recta is important?

A

It allows blood to flow thru the medullary tissue w/o disturbing the osmotic gradient. If blood flow was rapid the medullary concentrating gradient and the ability to concentrate urine would be lost

154
Q

Renin is released as a result of what 3 things?

A

response to beta adrenergic, decreased afferent arteriole perfusion, decreased Na

155
Q

Where is angiotensin I converted to angiotensin II?

A

lungs

156
Q

Aldosterone release is from which organ?

A

adrenal cortex

157
Q

Where is ANP produced?

A

cardiac atria

158
Q

What type of diuretic is ANP?

A

very potent

159
Q

3 stimuluses of release of ANP?

A

stretch, distention, increase in pressure of atria

160
Q

4 effects of ANP?

A

cause increase Na excretion, increase in urine flow, RBF, GFR

161
Q

Why are renal patients anemic?

A

lack erythropoietin

162
Q

What does erythropoietin do?

A

stimulates RBC production

163
Q

2 types of renal prostaglandins?

A

PGE2, thromboxane A2

164
Q

What is PGEs function?

A

important protective vasodilator during periods of hypotension and ischemia

165
Q

What does thromboxane A2 do?

A

contraction of vascular smooth muscle

166
Q

This regulates Ca metabolism with parathyroid and calcitonin?

A

vit D

167
Q

Renal failure patients often have abnormal (ion)?

A

calcium

168
Q

This is first hydrolyzed in the kidney to become active?

A

cholecalciferol

169
Q

Regarding acid base balance, H ions are excreted for?

A

Na

170
Q

How do kidneys control ECF H concentration?

A

excreting acidic or basic urine

171
Q

Major function of Bowman’s Capsule?

A

filtration

172
Q

All forms of anesthesia can depress renal function how much?

A

30-40%

173
Q

The change in renal function d/t anesthesia is directly correlated with?

A

degree of sympathetic block and blood pressure depression, impairment of autoregulation

174
Q

4 things which effect impairment of renal function d/t anesthesia?

A

age, type of surgery, comorbidities, CV depression

175
Q

How can you overcome the effects of anesthesia on kidneys?

A

maintenance of intravascular volume and normal BP

176
Q

How is it that potent anesthetic drugs suppress renal autoregulation?

A

neuronal involvement with SNS and PNS

177
Q

Anesthetic drugs do what to renal perfusion and renal vascular resistance?

A

decrease renal perfusion, increase renal vascular resistance

178
Q

Drugs that cause a catecholamine release do what 3 things to kidneys?

A

increase in renal vascular resistance, vasoconstriction, decrease RBF

179
Q

Inhalation agents do what to kidneys?

A

increase renal vascular resistance in response to lower SVR

180
Q

5 things which influence depression of renal function?

A

type and duration of procedure, physical status of pt, vol and lyte status, depth of anesthetic, choice of anesthetic

181
Q

2 ways heart can indirectly effect renal function?

A

decrease in BP below autoregulation will decrease RBF, blockade of SNS w regional

182
Q

How does neural system indirectly effect renal ftn during anesthesia?

A

SNS activation during periop period can increase renal vascular resistance and activate hormonal systems

183
Q

How does endocrine system indirectly effect kidneys?

A

induced stress response (surgery, hypoxia, hypotension) releases catecholamines which all reduce RBF

184
Q

High circulation of ADH and aldosterone can be caused by 3 things?

A

hemorrhage, positive pressure ventilation, upright position

185
Q

How are kidneys vulnerable to toxicity?

A

d/t vascular supply and increase in concentration in tubules during reabsorption

186
Q

Renal damage d/t toxins depends on what 3 things?

A

concentration of toxin, degree of protein binding in renal vs non renal tissue, the time kidneys are exposed to the toxin

187
Q

How does Fl alter renal ftn?

A

interfering with active transport of Na and Cl

188
Q

What are 2 other effects Fl ion has in kidneys?

A

potent vasodilator and inhibits ADH

189
Q

This anesthetic agent is associated with polyuric renal failure?

A

methoxyflurane

190
Q

Fl ions interferes with kidneys’ ability to?

A

concentrate urine

191
Q

Fluoride excretion is dependent on? And this makes pts with preexisting renal conditions more vulnerable.

A

GFR

192
Q

6 symptoms of Fl toxicity?

A

polyuria, hypernatremia, serum hyperosmality, elevated BUN and creatinine, decreased creatinine clearance

193
Q

Why is nephrotoxicity with methoxyflurane greater than w other halogenated anesthetics?

A

has high bg partition coefficient so wants to hang around in body longer so there is a slower metabolism and a longer exposure to Fl ions

194
Q

Methoxyflurane produces Fl ions and?

A

vasopressin resistant polyuria

195
Q

Is enflurane toxic to kidneys?

A

no if it is given over a long period of time it may create mild renal impairment

196
Q

Is isoflurane okay for the kidneys?

A

yes; but not recommended to use because it is defluronated slightly

197
Q

Is Desflurane okay for kidneys?

A

yes bc it has a low bg partition coefficient and is readily eliminated. it does produce Fl metabolites but it strongly resists biodegration/metabolism

198
Q

What % of the Sevoflurane dose is metabolized?

A

5

199
Q

How does sevoflurane Fl ion production compare to methoxyfluranes?

A

1/4 the production

200
Q

4 things which increase the likelihood of compound A nephrotoxicity from sevo?

A

high concentration of agent, fresh baralyme, increased temp in CO2 absorbed (d/t low flow rates or increased CO2 production)

201
Q

Is compound A toxicity from sevo significant for humans?

A

it has only been found in animals

202
Q

FDA recommendations for Sevo?

A

recommends 1L/min if 1 hour or less otherwise 2L/min if more than one hour

203
Q

4 major causes of renal failure?

A

shock, trauma, sepsis, exposure to toxins

204
Q

What are some toxins for renal failure?

A

aminoglycosides, iodinated dyes, drug interactions, hemoglobin and myoglobin loads

205
Q

Most common cause of ARF?

A

renal hypoperfusion

206
Q

What is critical in determining the severity of renal failure?

A

duration and magnitude of initiating renal insult

207
Q

3 ways to maintain renal ftn during surgery?

A

give adequate intravascular volume, maintain CO, and avoid drugs that decrease renal perfusion

208
Q

Rapid deterioration in renal function results in?

A

retention of nitrogen waste products (azotemia)

209
Q

1/2 the pts requiring dialysis results from? And what is the mortality rate?

A

periop ARF; 50%

210
Q

How is ARF diagnosed?

A

increase in BUN and creat over 24-72 hours

211
Q

Cause of prerenal failure? And treatment?

A

HD or endocrine factors that impair renal perfusion; correction of hemodynamics

212
Q

Causes of ATN/intrarenal failure? Treatment of

A

tissue damage (ischemia, drugs, release of HGB/myoglobin)

213
Q

Treatment of ATN?

A

parenchymal damage requires dialysis

214
Q

Most difficult type of renal failure to treat?

A

intra/ATN

215
Q

Cause of postrenal failure?

A

obstruction

216
Q

Classifications by urine flow rates?

A

oliguric, non oliguric, polyuric

217
Q

What’s oliguric renal failure? Examples?

A

urine output

218
Q

What is non oliguric renal failure?

A

make urine at an adequate rate but it is not concentrated enough bc it’s poisoned or ischemic

219
Q

What is polyuric renal failure?

A

elevated BUN, creatinine, urine output >2.5 L/day

220
Q

2 causes of polyuric renal failure?

A

methoxyflurane, inorganic fluoride production

221
Q

What is chronic renal failure?

A

progressive decrease in functional nephrons, GFR, RBF, tubular function, reabsorptive capacity

222
Q

Symptoms of chronic renal failure are seen once what % of functioning nephrons are left?

A

40

223
Q

What is renal insufficiency?

A

10-40% of functional nephrons exist

224
Q

What % of functional nephrons are lost in ESRD?

A

95%

225
Q

What happens in ESRD?

A

acid/base, lyte and concentrating/diluting mechanisms fail, can lead to uremia, volume overload, CHF, dialysis required

226
Q

Most common cause of ESRD?

A

glomerulonephritis

227
Q

How does glomerulonephritis damage the kidneys?

A

deposits antigen antibody complexes in the glomeruli

228
Q

S/s glomerulonephritis?

A

hematuria, proteinuria, HTN, edema, elevated creatinine

229
Q

What is goodpasture syndrome?

A

combo of pulmonary hemorrhage and glomerulonephritis

230
Q

How is the prognosis for good pasture syndrome?

A

prognosis is poor

231
Q

Renal failure occurs how long after diagnosis of goodpasture syndrome?

A

1 year

232
Q

6 manifestations of nephrotic syndrome?

A

heavy proteinuria, hypoalbuminemia, edema and ascites 2ndary to decreased plasma oncotic pressure, hypovolemia, hyperlipidemia, hypercoagulability

233
Q

What is hepatorenal syndrome?

A

acute oliguria in pt with decompensated cirrhosis of the liver

234
Q

How does liver cirrhosis contribute to ARF?

A

decreases GFR and RBF

235
Q

Treatment for hepatorenal syndrome?

A

portocaval shunt

236
Q

2 s/s of hepatorenal syndrome?

A

hypovolemia, circulating liver toxins

237
Q

Some anesthetic considerations for pt with CRF?

A

pruritis (d/t urea), chronic anemia (lack of erythropoietin), metabolic acidosis, electrolyte disturbances, coagulopathies (increased bleeding time, GI bleed, epistaxis, hemorrhagic pericarditis, subdural hematoma), platelet dysfunction), cardiac dysrthymias, cardiac dysfunction, CAD, pericarditis, chronic HTN, pulmonary congestion and edema, gastroparesis, increased infection, neuro changes (uremic encephalopathy, peripheral and autonomic neuropathies)

238
Q

3 negative effects from HD?

A

hypoxia, hypotension, neuro changes

239
Q

3 types of vascular devices for pt receiving HD?

A

central catheter, AV fistula, quinton catheters

240
Q

4 questions ab dialysis pt that should be answered?

A

last treatment? when is next scheduled treatment? how much weight was taken off? post dialysis labs

241
Q

Some conditions which put the pt at risk for renal failure?

A

sepsis, obstructive jaundice and hepatorenal failure, obstetrical emergencies, rhabdo, myoglobinuria, cardiopulmonary bypass, AAA repair, coma or prolonged immobilization

242
Q

Some preop tests that should be examined before renal pt has surgery?

A

EKG (hyperkalemia, hypocalcemia), echo (LV dysfunction, CHF), chest x ray (uremic lung, pulmonary congestion), CBCP, lytes, glucose, BUN, creat, fractional excretion of filtered Na, UA (specific gravity, urine osmolality, proteinuria), creat clearance

243
Q

Most sensitive indicator of GFR?

A

creat clearance

244
Q

Normal creat clearance?

A

95-150 mL/min

245
Q

When should a pt have a catheter?

A

anticipated blood loss, deliberate hypotension, use of diuretics, potential damage to ureters, operation >4 hours, aortic cross clamp, cardiopulmonary bypass

246
Q

1 cause of low urine output?

A

kidneys not getting perfusion d/t not enough volume

247
Q

4 causes of mechanical obstruction decreasing UO?

A

kinked tubing, foley not in bladder, too much xylocaine in urethra, position (T burg)

248
Q

Assume oliguria is what until proven otherwise?

A

prerenal

249
Q

How can you maximize RBF?

A

cardiac function

250
Q

3 things to check the field for if low UO?

A

retractors, ligations of ureter, trauma to bladder

251
Q

How might the volume of distribution change in a renal failure patient?

A

might have a larger Vd; drugs that are highly protein bound may have a greater effect bc of hypoalbuminemia

252
Q

How does acidosis in renal pt affect drugs?

A

more unionized form of drug available and therefore able to cross lipid membranes faster

253
Q

How does anemia affect drugs?

A

increases CO and delivery to brain

254
Q

How does uremia alter drugs?

A

alters integrity of BBB, increases sensitivity

255
Q

What might happen to metabolites in renal patient?

A

may accumulate and become physiologically active

256
Q

Anesthetic drugs are more variable for what 4 reasons in patients with renal probs?

A

increased Vd, protein binding, low pH, dependence on renal excretion

257
Q

How may ketamine effect a renal pt?

A

may worsen HTN d/t catecholamine release, metabolites may accumulate

258
Q

How might sodium pentothal have a changed effect in renal pts?

A

it is highly protein bound so it may have an exaggerated effect

259
Q

When is a good time to use etomidate in renal pt?

A

if diminished LV function, CAD

260
Q

What do you have to do with propofol dose in ESRD pt?

A

increase dose d/t hyperdynamic state

261
Q

Renal pts will have a greater sensitivity to what drugs if hypoalbuminemic?

A

benzos

262
Q

What happens when you give narcotics to a renal pt?

A

increased Vd, may have exaggerated response, slow elimination 1/2 life

263
Q

Caution with what 3 narcs in renal pts?

A

morphine (prolonged resp depression), meperidine (normeperidine may cause seizures, resp depression), sufentanil (highly variable clearance and 1/2 life)

264
Q

Inhalation agent to avoid in renal failure?

A

methoxyflurane (and she recommends sevo too)

265
Q

You can use Suxxs in those pts with a K

A

5

266
Q

Increased block from suxxs can occur when in renal pt?

A

accumulation of metabolites

267
Q

How does block from roc, vec, and mivacurium change in renal pts?

A

may be prolonged and unpredictable

268
Q

Paralytics of choice in those with renal issues d/t predictability from hoffman elimin>

A

cis, atracurium

269
Q

You should avoid these drugs in renal patients because of inhibition of prostaglandin synthesis?

A

NSAIDs

270
Q

Should you give anticholinergics in renal pts?

A

use cautiously bc its active metabolites are excreted in urine

271
Q

What do you have to do to the dose of 5-HT3 blockers in renal pts?

A

nothing

272
Q

Why do you have to be careful with metaclopramide use in renal pts?

A

may accumulate and cause EPS and athatosis

273
Q

Can you use H2 blockers in renal pts?

A

they have a wide therapeutic window so you don’t need to avoid but use judiciously bc they are dependent on renal function

274
Q

Why do you have to be careful with use of phenothiazines in renal pts?

A

potentiation of CNS effects; she says just to avoid

275
Q

Advantage of regional anesthesia in CRF pt?

A

minimal change in HDs

276
Q

Avoid regional in what 4 types of pts?

A

clotting disorders, peripheral neuropathy, high anxiety, prolonged procedures

277
Q

How does acidosis affect regional block?

A

faster onset and shorter duration

278
Q

A sympathetic block may cause?

A

hypotension and correction of that may lead to pulmonary edema

279
Q

Anesthetic implications for induction?

A

inject drugs slowly to avoid decrease in BP from autonomic dysfunction, may need to modify doses, and use non renal eliminated drugs

280
Q

Safest type of ventilation in renal patient?

A

controlled ventilation

281
Q

Spontaneous ventilation in renal patient is bad bc?

A

can result in resp acidosis, potentially severe CV depression, increase in serum K (resp acidosis moves K out of cell)

282
Q

Anemic patients may require a higher what?

A

FiO2

283
Q

What should you use to treat HTN in renal patients?

A

vasodilators

284
Q

Preop hydration in renal pts should be?

A

NS 10-20 mL/kg

285
Q

What solutions should you avoid in renal pts?

A

LR or K containing fluids

286
Q

urine output should be what in renal pts during surgery?

A

0.5-1 mL/kg/h

287
Q

When should you use diuretics in renal pt during surgery?

A

when well hydrated

288
Q

Lasix may be useful in what 3 situations?

A

obstructive jaundice, contrast media, pigment in urine

289
Q

Lasic can worsen what 2 things?

A

hypoperfusion and renal ischemia in hypovolemic pts

290
Q

Prophylactic admin of mannitol can be used in what patients?

A

hydrated pts

291
Q

This diuretic is the most often prescribed one and is used for essential HTN?

A

thiazide

292
Q

How does thiazide work?

A

inhibits reabsorption of Na

293
Q

Side effects of thiazide?

A

hypokalemia, muscle weakness, potentiation of NMDRs

294
Q

How do loop diuretics work?

A

inhibit reabsorption of Na and Cl, augments the secretion of K

295
Q

How do osmotic diuretics work?

A

they’re filtered by the glomeruli and not reabsorption w/in renal tubules increasing osmolality leading to increased secretion of water

296
Q

How do aldosterone antagonists work?

A

offsets the loss of K with thiazide diuretics , watch for hyperkalemia

297
Q

Side effects of lithotomy position?

A

decreased FRC, leading to atelectasis and hypoxia; rapid lowering of the legs decreases venous return and can result in hypotension; failure to position legs correctly can result in iatrogenic injuries

298
Q

What is a cystoscopy and what type of anesthesia is used for it?

A

where camera is passed in to bladder; usually MAC or local

299
Q

What is brachytherapy?

A

radioactive seeds are placed for prostate cancer

300
Q

3 considerations for pt undergoing brachytherapy?

A

low EBL, usually GA but can be spinal or epidural and use LMA, lithotomy position

301
Q

Anesthetic concerns with extracorporeal shock wave lithotripsy?

A

sync shock waves w R waves, pancreatic or hepatic damage, renal damage, platelet dysfunction, usually done MAC or GA, cardiac dysrhythmias, pacers, AICDs

302
Q

3 contraindications for ESWL?

A

pregnancy, AAA, morbid obesity

303
Q

When is simple prostatectomy done?

A

removal of prostate too large for TURP, BPH

304
Q

What is done in radical prostatectomy?

A

removal of prostate gland, bladder neck, seminal vesicles, ampullae of vas deferens, pelvic lymph node dissection

305
Q

What is a radical retropubic prostatectomy?

A

removal of prostate and structures via vertical incision below the umbilicus

306
Q

Some anesthetic considerations for retropubic prostatectomy?

A

EBL may be high (500 or so), pt can bleed quickly from dorsal vein, will have foley which is usually clamped so UO is difficult to assess (check field for blood loss), when bladder is open urine will mix with blood and account for some of the volume

307
Q

Some considerations for laparoscopic or robotic RRP?

A

they’re in extreme T burg so venous congestion may occur, high risk for peripheral nerve injury, ventilation may be difficult d/t position and air in abdomen, bilateral arms tucked, 2 PIVs should be in place and possible a line

308
Q

Some considerations for radical perineal prostatectomy?

A

extreme lithotomy, shoulder braces on acromium processes, high risk for nerve injury, less blood loss than RRP, pts who have received bleomycin are at risk for pulmonary insufficiency, O2 toxicity, and fluid overload

309
Q

What is a radical nephrectomy?

A

excision of perinephritic fat and fascia, proximal 2/3 ureter and para aortic lymph nodes

310
Q

Anesthetic implications for radical nephrectomy pts?

A

general anesthesia, may have epidural, standard monitors, possible a line, potential for blood loss, 2 PIVs, avoid nephrotoxic drugs, potential for high EBL,

311
Q

Positioning for radical nephrectomy?

A

supine or lateral with axillary roll and bean bag

312
Q

Fluid management for radical nephrectomy?

A

NS/LR 6-8 mL/kg/hr

313
Q

Urine output during radical nephrectomy should be?

A

0.5 mL/kg/hr

314
Q

3 meds that may help with urine output during radical nephrectomy?

A

mannitol, lasix, dopamine

315
Q

Some complications/anesthetic concerns for radical nephrectomy pts?

A

potential for pneumo, decreased venous return if pressure on the vena cava, increased airway pressures with retraction of diaphragm, tumor involvement into IVC, potential for large blood loss with embolization of tumor

316
Q

Anesthetic considerations for donor nephrectomy pt?

A

lateral or supine position, maintain UO w lasix or mannitol if needed, high volume of fluids, good pain control

317
Q

Why is laparoscopic preferred for donor nephrectomy pts?

A

shorter recovery times, less bleeding, less respiratory infections

318
Q

Dialysis should be w/in how many hours for renal transplant?

A

24 hours

319
Q

K should be less than and what should be corrected for renal transplant cases?

A
320
Q

Lines needed for renal transplant pt? And goal for SBP?

A

a line, CVP 10-15, SBP > 100

321
Q

Hypotension may occur during what part of a renal transplant?

A

unclamping of renal artery

322
Q

Hyperkalemia often occurs when during renal transplant?

A

after release of clamp

323
Q

How is an ileal conduit created for cystecomy?

A

ileum is isolated, bowel is reanastomosed, ureters are connected to the segment of the ileum, and stoma is created

324
Q

How is a neobladder made?

A

segment of ileum is removed and fastened in to pouch, bowel is reanastomosed, ureters and urethra are connected to pouch

325
Q

Anesthesia for cystectomy?

A

usually general but can be combined w epidural

326
Q

Fluid management for cystectomy pt?

A

LR/NS 6-10 mL/kg/hr

327
Q

2 preop considerations for cystectomy pt?

A

most are smokers; possible underlying renal impairment

328
Q

Treatment of TURP syndrome?

A

hypertonic saline and lasix

329
Q

What type of anesthesia is preferred for TURP?

A

spinal; to monitor s/s of hyponatremia, less likely to mask symptoms and reduces venous thrombosis

330
Q

2 ways to decrease risk of TURP syndrome?

A

NaCl in irrigation and special cautery

331
Q

Common complications of transurethral procedures?

A

hypervolemia, hyponatremia, bladder perf, bleeding, glycine ammonia toxicity, electrical hazards, hypothermia, bacteremia

332
Q

S/s TURP syndrome?

A

HA, restlessness, confusion, cyanosis, arrhythmias, hypotension, seizures

333
Q

Absorption of fluid in TURP is dependent upon ?

A

length of procedure and height of irrigating fluid

334
Q

In response to hypotension what do the afferent and efferent arterioles do?

A

afferent dilates and efferent constricts

335
Q

2 lab values indicating renal impairment?

A

BUN > 30; Cr > 1.5

336
Q

2 lab values of CKD?

A

proteinuria; GFR

337
Q

Lab values for ARF?

A

abrupt decrease in renal ftn, increased BUN/creat, decreased UO

338
Q

Lab values for CRF?

A

GFR

339
Q

End stage renal disease is?

A

loss of renal function for > 3 months

340
Q

What does GFR do w age?

A

declines

341
Q

Lab value that can estimate GFR if unable to obtain 24 hour urine specimen?

A

creatinine clearance

342
Q

Normal GFR?

A

100-130 mL/min

343
Q

Normal creat clearance for male and female?

A

male: 97-137; female: 88-128

344
Q

S/s that occur when BUN > 40?

A

malaise, insomnia, pruritis, N/V, anemia, Na/H2O retention, bone pain, paresthesia and tetany from hypocalcemia

345
Q

S/s when BUN > 50/60?

A

worse CNS symptoms, myoclonic twitching and mental slowing

346
Q

> 80% of renal patients have this cardiac complication? And what is the most frequent cause?

A

HTN; Na and H2O retention

347
Q

What increases the risk of seizures and hypotensive episodes in renal pts?

A

anemia

348
Q

What can hypoparathyroidism do to bone marrow?

A

fibrosis

349
Q

What type of RBC can renal pts have?

A

abnormal rbc membranes with greater osmotic fragility

350
Q

Why is thrombocytopenia common in renal pt?

A

heparin used in dialysis

351
Q

Despite labs showing normal values, why can renal pts have excessive bleeding?

A

platelets dysfunction

352
Q

What type of GI issues do renal pts have?

A

delayed gastric emptying especially in men

353
Q

Why do renal pts often have LVH?

A

often have cardiac autonomic neuropathy

354
Q

5 common electrolyte disturbances in renal pt?

A

hypocalcemia, hypophosphatemia, hyperkalemia, hypokalemia, hyponatremia

355
Q

Postpone surgery if K >?

A

5.9

356
Q

Hypokalemia is K

A

3.3

357
Q

EKG is indicated in patients with a creatinine >?

A

2.0

358
Q

Hyponatremia can be caused by?

A

bowel prep, vomiting, diarrhea, osmotic diuresis from uremia or hyperglycemia

359
Q

Do you need labs on day of surgery for dialysis pt?

A

yes

360
Q

Some surgeries which place pt at risk for renal injury?

A

liver transplant, increased intra abdominal pressure involved, generalized embolization

361
Q

Some meds which can cause renal damage?

A

cimetidine, chemo, abx, phenytoin, diuretics

362
Q

Pts most at risk for contrast induced nephropathy?

A

diabetics and CKD

363
Q

Contrast induced nephropathy occurs when creat rises how much?

A

25% above baseline

364
Q

Radiocontrast media does what to GFR in most ppl?

A

mild decrease

365
Q

Some modalities to reduce risk of CIN?

A

d/c NSAIDs, mucomyst, IV hydration with NS, HCO3, limit contrast volume 150 after procedure, avoid contrast for 10 days if possible

366
Q

4 renoprotective strategies?

A

dopamine, fenoldepam, furosemide, mannitol

6901 (18 decks)

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