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Anesthesia & Coexisting Disease > Final_Renal > Flashcards

Final_Renal Flashcards

1
Q

Kidneys are responsible for

A
  • water conservation
  • electrolyte homeostasis
  • acid-base balance
  • several neurohumoral/ hormonal functions
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2
Q

AKI- types

A
  • prerenal (azotemia)
  • renal (kidney itself)
  • post-renal (outflow obstruction)
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3
Q

AKI- tx

A

● No specific tx
● Management aims to limit further injury in sepsis:
○ Treat underlying cause
○ MAP>65mmHg
○ Fluid resuscitation (LR)
○ Vasopressor therapy (Norepi in sepsis = safe for kidneys)
○ Activated C-Protein
○ Steroid replacement (for adrenal insufficiency)
○ Dialysis - mainstay for severe AKI

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4
Q

AKI - anesthesia management

A
  • Rx dosing adjustments: decrease dose, increase interval
  • same as tx of AKI
  • only life saving surgery for pts with AKI
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5
Q

CKD - what is it?

A

Kidney damage with GFR <60 mL/min/1.73m​ for 3 mos or more

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6
Q

CKD - progression

A

● Stage I
○ GFR decreases→ increases in BUN + Creat
○ Non-linear process - i.e. Creatinine can be normal while 50% dec. GFR
● Stage II
○ Hyperkalemia
○ Body compensates - ↑ blood flow to collecting tubules to get rid of K+
● Stage III
○ Homeostasis and regulation of extracellular fluid compartment volume
■ System starts to become overwhelmed
■ Biggest increase in damage over last ~ decade

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7
Q

CKD complications

A
  • uremic syndrome
  • renal osteodystrophy
  • anemia
  • uremic bleeding
  • neuro changes
  • CV changes (HTN, HL, silent MI, uremic pericarditis)
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8
Q

CKD management

A

● Aggressive tx of underlying cause
● Pharmacologic therapy (delay dx progression, prevent further complications)
● Preparation for RRT (access, AV fistula–> peritoneal HD, iHD, RRT)
● Manage BP
● Dietary interventions
● Epo for anemia​ at all stages​ of CKD
● Lifestyle modifications

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9
Q

CKD - anesthesia management (pre-op, induction)

A

Preop: LABS (chem), coagulopathies, anemia; HD regimen

Induction:

-Induction drugs?
■ Most safe to use
■ Thiopental=Dose ↓
(d/t ↑ volume of distribution, ↓ protein binding)

  • response
    HOTN​ almost immediately after: be prepared=pressors

-Is succinylcholine safe to use?
K+ released from Sux not exaggerated in CKD=safe to use

*Attenuated SNS activity impairs compensatory vasoconstriction
○ Exaggerated (​HD) response to:
■ blood volume
■ PPV
■ body position changes

○ ACEs/ARBS → more HOTN intraop esp if haven’t followed guidelines for pre-op use of Rx

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10
Q

CKD - anesthesia management (maintenance)

A

Maintenance:

  • Balanced anesthesia
    (VA + muscle relaxants + opioids = equal mix)
  • What about sevoflurane?
    ○ Fluoride Toxicity + Compound A accumulation
    ○ Do providers use Sevo? Yes in real world (higher flows)

● What about volatile agents?
○ Safe - but could use cause precipitous drop in BP d/t decreased SVR
○ Know which VAs drop SVR more than others
● What about TIVA? ✔ Fine
● What about muscle relaxants?
○ Slowed excretion of Roc/Vec
○ Cisatracurium: No change
● What about neostigmine?
○ MOA prolonged
○ Not a problem if ​reversing
● What about opioids?
○ morphine/meperidine depends on renal clearance
○ Morphine metabolite may accumulate & cause post-op respiratory depression
○ Careful use of ​longer acting​ opioids → make sure breathing well post-op

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11
Q

nephrolithiasis

A

Kidney Stone

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12
Q

Biggest causative factor of nephrolithiasis

A

Calcium Oxylate

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13
Q

Struvite

A

Magnesium ammonium phosphate (often formed from infxn process: UTI)

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14
Q

Biggest growth in which kidney failure over 2014-2017?

A

Stage 3: GFR 30-59

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15
Q

TURP syndrome is due to

A

IV fluid volume shifts + plasma solute effects caused by absorption of irrigation solution

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16
Q

CKD - anesthesia management (ivf)

A

-Intraoperative UO is not predictive of post-op renal insufficiency

-When to bolus IVF? What about K in the fluid?
○ Severe renal dysfunction that don’t req HD or pts w/o renal dx undergoing surgical procedure with high incidence of post-op renal failure – these patients may benefit from pre-op hydration with balanced salt solution

17
Q

Risks - CKD

A
  • avoid bp cuff on AVF arm
  • use hand for PIV, access catheter LAST
  • prone to infxn, skin breakdown
18
Q

Caution with which Rx in CKD?

A

Opioids

19
Q

Technique used for AV fistula placement

A

PNB: brachial plexus block

20
Q

TURP syndrome

A

complication characterized by symptoms changing from an asymptomatic hyponatremic state to convulsions, coma and death due to absorption of irrigation fluid during TURP

21
Q

Location of kidney stones

A

Pelvis
-usually painless
Ureter
-extremely painful, flank pain, N/V, sweaty, pale, hematuria

ureteral obstruction may cause s/s of renal failure

22
Q

What may occur if close to passing a kidney stone?

A

Increased hematuria

23
Q

Treatment: Nephrolithiasis

A

ESWL

also ID-ing the composition of stone + correcting predisposing factor: hyperparathyroidism, UTI, or gout

24
Q

ESWL

A
  • Extracorporeal Shock wave Lithotripsy (non-invasive)
  • Focused high intensity acoustic impulses directed at stone in renal pelvis
  • Basically pulverizes stone → dust → washed out thru urine
25
Q

BPH Surgical Options

A

TUIP Trans-urethral incision of the prostate

TURP
(Trans-urethral resection of the prostate)
● Surgical resection of prostate (radical=remove entire gland: indicated for CA; retropubic, peritoneal (lose nerve fxn))
● Electrocautery or sharp excision
● Laser ablation (laser prostatectomy): req goggles

26
Q

How to alter course of CKD progression?

A

Biggest: HTN/BG

-ACEI/ARBs + strict glycemic control

27
Q

ACEI/ARBs

A
  • Decrease systemic HTN + glomerular HTN

- Renoprotective effects (Reductions in proteinuria, Slowing progression of glomerulosclerosis/neuropathies)

28
Q

Cause of anemia in CKD

A

Decreased erythropoietin production by kidneys

*also: excess PTH production – replacing bone marrow with fibrous tissue

29
Q

Tx: Anemia in CKD

A 
exogenous Erythropoietin (Epoetin) or darbopoetin
*in ALL stages of CKD
30
Q

Target Hgb in CKD

A

10-11.5 mg/dL

*AVOID BLOOD TRANSFUSIONS

31
Q

Target Hgb in CKD

A

10-11.5 mg/dL

*AVOID BLOOD TRANSFUSIONS

32
Q

Why is it important to avoid blood transfusions in CKD?

A

Result in sensitization of antigens of human leukocyte antigen complex → makes future kidney transplantation less successful

33
Q

principal factor contributing to TURP syndrome

A

hypo-osmolality

contributes to neuro + hypovolemic changes

Anesthesia & Coexisting Disease (23 decks)

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