Advanced | Urologic and Renal Anesthesia

Question 1

Which solution puts the patient to potentially high risk of ACUTE INTRAVASCULAR VOLUME EXPANSION?

A. Distilled Water
B. Glycine (1.5%)
C. Mannitol (5%)
D. Sorbitol 3.3%)

Answer 1

C. Mannitol (5%)

Question 2

Which of the following solution is considered ISOSMOLAR?

A. Distilled Water
B. Glycine (1.5%)
C. Mannitol (5%)
D. Sorbitol 3.3%)

Answer 2

C. Mannitol (5%)

Question 3

Which of the following values meets the criteria for CKD?

A. GFR < 60 mL/min
B. GFR < 80 mL/min
C. GFR > 50 mL/min
D. FENa <1%
E. Both A & D

Answer 3

A. GFR < 60 mL/min

A GFR below 60 mL/min meets criteria for chronic kidney disease (CKD) and is considered impaired, while values lower than 15 mL/min are often associated with uremic symptoms and may require dialysis.

Question 4

Which of the following statement is INCORRECT regarding CKD patients?

A. The inducting dose of Thiopental is reduced due to exaggerated clinical effects

B. Anticholinesterases pharmacokinetics are affected by renal failure

C. Benzodiazepines metabolites accumulate with repeated dosages among anephric patients

D. Significant dosage alteration of the anticholinesterase is required when antagonizing neuromuscular blockade in pts with reduced renal function

Answer 4

D. Significant dosage alteration of the anticholinesterase is required when antagonizing neuromuscular blockade in pts with reduced renal function

Statement D is INCORRECT

The anticholinergic agents atropine and glycopyrrolate, used in conjunction with the
anticholinesterases, are similarly excreted by the kidney. Therefore, no dosage alteration of the anticholinesterases is required when antagonizing neuromuscular blockade in patients with reduced kidney function.

Question 5

Which of the following OPIOID has a safest profile among ESRD patients?

A. Morphine
B. Fentanyl
C. Remifentanil
D. Hydromorphone
E. Meperidine

Answer 5

B. Fentanyl

Fentanyl appears to be a better choice of opioid for use in ESRD because of its lack of active metabolites, unchanged free fraction, and short redistribution phase. Small-to-moderate doses, titrated to effect, are well
tolerated by uremic patients.

Question 6

Which of the following medications has a safe renal profile?

A. DPP-4 inhibitors
B. SGLT2 Inhibitors
C. Biguanides
D. Sulfonylureas

Answer 6

B. SGLT2 Inhibitors

e.g. canagliFLOZIN, dapagliFLOZIN, and empagliFLOZIN, and bexagliFLOZIN

SGLT2 inhibitors work at the level of the proximal tubule to prevent the reabsorption
of approximately 90% of filtered glucose. SGLT2 inhibitors lower glomerular capillary hypertension and hyperfiltration leading to improved cortical oxygenation and less tubular glucotoxicity.

Question 7

Which of the following is the MOST accurate in describing the renal function of a neonate?

A) A urine output of < 1 mL/kg/hr is normal after 1 week of life

B) At birth, the glomerular filtration rate is low but it increases greatly in the first few days of life

C) At birth, the renal vascular resistance increases, which decreases blood flow to the kidneys

D) The increased glomerular filtration rate and increased tubular function allow for better concentration and dilution of urine

Answer 7

B) At birth, the glomerular filtration rate is low but it increases greatly in the first few days of life

Neonates have a low glomerular filtration rate (GFR) due to a high renal vascular resistance, low systemic arterial pressure, low permeability of the glomerular capillaries, and the small size of the glomerular capillaries.

At birth, a high systemic arterial pressure with a lower renal vascular resistance increases the amount of renal blood flow.

The GFR increases significantly in the first few days of life and reaches adult levels at 2 years of age.

This decreased GFR and tubular function impair the neonate’s ability to dilute and concentrate the urine. While the urine output is expected to be low on the first day of life, urine output afterward should be at least 1-2 mL/kg/hr.

Question 8

Which NMB has a minimal renal excretion of the unchanged parent compound and therefore safe in CKD patients:

A. Rocuronium
B. Pancuronium
C. Vecoronium
D. Cis-atracurium

Answer 8

D. Cis-atracurium

Muscle relaxants are the most likely group of drugs used in anesthetic practice to produce prolonged effects in ESRD because of their dependence on kidney excretion.

Only succinylcholine, atracurium, cis-atracurium, and mivacurium appear to have minimal kidney excretion of the
unchanged parent compound

Question 9

Which part of the glomeruli does mannitol primarily act?

A. Medullary loop of Henle

B. Proximal tubule

C. Distal tubule

D. Collecting duct

Answer 9

Medullary Loop of Henle

Remember that osmotic diuretics are unable to be reabsorbed by the renal tubules.&raquo_space; Increase in osmolarity&raquo_space;

Question 10

A 40 year old patient is being evaluated for an elective surgery. She is a known hypertensive and diabetic of which she takes SLGT-2 inhibitors. When do you discontinue the SLGT2 inhibitors prior to SURGERY?

A. 24 hours

B. 48 hours

C. 3 days

D. 1 week

Answer 10

C. 3 days

• 3 to 4 days prior to elective surgery
• This is to prevent the possibility of a serious euglycemic ketoacidosis.

The most dreaded side-effect is AKI.

Question 11

Which of following volatile agents WILL NOT predispose an otherwise healthy patient in developing polyuric AKI due to compound A?

A. Enflurane

B. Sevoflurane

C. Desflurane

D. Isoflurane

Answer 11

C. Desflurane - Carbon Monoxide

highest propensity to compound A buildup are:

SEVOflurane
ENflurane
ISOflurane

• > 50 mm/L may cause polyuric AKI.

Question 12

Which of the following value of Hyponatremia where the typical symptoms begin to occur:

A. < 130 mmoL/min

B. < 120 mmoL/min

C. < 110 mmoL/min

Answer 12

<120 mmoL/min

Symptomatic patients with serum sodium concentrations <120 mEq/L should have their extracellular tonicity corrected
with hypertonic saline.

• Sodium chloride in a 3% solution should be infused
  at a rate no greater than 100 mL/hr.

Question 13

Hypertonic saline solution is discontinued when the correction of hyponatremia exceeds which value?

A. 120 mEq/L

B. 135 mEq/L

A. 115 mEq/L

A. 140 mEq/L

Answer 13

A. 120 mEq/L

Serum electrolytes should be followed closely, and the hypertonic saline discontinued when the patient is asymptomatic or serum sodium concentration exceeds 120 mEq/L.

Treatment with hypertonic saline has been associated with development of demyelinating central nervous system lesions (central pontine myelinolysis)
due to rapid increases in plasma osmolality, and this approach should be reserved for patients with severe, life-threatening symptoms.

Question 14

Which of the following solutions used in the TURP procedure has an osmolality closest to that of plasma in an otherwise healthy patient?

A. Glycine 1.2%

B. Mannitol 5%

C. Distilled water

D. Sorbital 3.5%

Answer 14

B. Mannitol 5%

Normal plasma osmolality = 275 to 295 mOsm/kg

Question 15

True or False

Renal failure has no effect on the clearance of remifentanil, but elimination of the principal metabolite, remifentanil acid, is markedly REDUCED.

Answer 15

True

Question 16

TRUE or FALSE

Kidney pain sensation is conveyed back to spinal cord segments T10 through L1 by
sympathetic fibers.

Answer 16

TRUE

Question 17

TRUE or FALSE

Glycine has structural similarities to aminobutyric acid, the visual disturbances induced by Glycine are thought to reflect neurotransmitter-mediated brainstem or cranial nerve inhibition rather than cerebral edema

Answer 17

TRUE

Question 18

True of TURBT except:

A. A serious intraoperative complication of
TURBT is bladder perforation by the rigid cystoscope during tissue resection, which occasionally occurs due to unexpected patient movement

B. muscle relaxation is preferred during general anesthesia, particularly in lateral wall resections where the obturator nerve may be stimulated by electrocautery

C. contraction of the ipsilateral thigh muscles is elicited due to stimulation of OBTURATOR nerve

D. Neuraxial anesthesia to the T6-T8 dermatomal level is necessary

Answer 18

D. Neuraxial anesthesia to the T6-T8 dermatomal level is necessary

Question 19

True of Glomerular Filtration:

A. Production of urine begins with water and solute filtration from plasma flowing into the glomerulus via the afferent arteriole.

B. The two major determinants of filtration pressure are glomerular capillary pressure and glomerular oncotic pressure.

C. The glomerular oncotic pressure is directly dependent on plasma oncotic
pressure.

D. Afferent arteriolar dilatation enhances GFR by increasing glomerular flow, which in turn elevates glomerular capillary pressure.

E. All of the above

Answer 19

ALL OF THE ABOVE

Question 20

True of electrolyte imbalance among Uremic Syndrome patients EXCEPT:

A. Hypernatremia
B. Hypermagnesemia
C. Hyperphosphatemia
D. Hyperkalemia

Answer 20

A. Hypernatremia

The electrolyte imbalance associated with CKD are:

Hyperkalemia, Hyperphospatemia, Hypermagnesemia, Hypercalcemia or Hypocalcemia, Hyponatremia, and Metabolic Acidosis

Question 21

Transient post-operative visual syndrome is associated with what solution?

Answer 21

GLYCINE (1.5%)

Question 22

This provides pain sensation to the penis:

A. Pudendal Nerve
B. Sympathetic segments from S2-24
C. Cutaneous nerve which projects to lumbo-sacral segments
D. Lower thoracic and upper lumbar segments

Answer 22

A. Pudendal Nerve

The pudendal nerve provides pain sensation to the penis via the dorsal nerve of the penis.

Question 23

This can be used as a surrogate for
measure of osmolarity:

A. urine specific gravity

B. creatinine clearance

C. serum albumin

D. creatinine

Answer 23

Urine specific gravity

High specific gravity (>1.018) implies preserved kidney concentrating ability.

Question 24

The sympathetic innervation of the Ureters is supplied by?

A. S2-24

B. L1-S2

C. L1-S4

Answer 24

S2-S4 Spinal Segments

Question 25

The Na+/K+-ATPase pump on the basolateral surface (blood side) of kidney tubular cells is primarily responsible for active pumping of Na+ out of cells into blood in exchange for K+. This pump causes a net movement of: A. 2 K+ inside for every 3 Na+ outside B. 2 K+ outside for every 3 Na+ inside C. 2 K+ inside for every 1 Na+ outside D. 2 K+ inside for every 4 Na+ outside

Answer 25

2 K+ inside for every 3 Na+ outside Under normal conditions, kidney function assures that <1% of the filtered Na+ load enters the urine (i.e., the FENa is <1%). The Na+/K+-ATPase pump on the basolateral surface (blood side) of kidney tubular cells is primarily responsible for active pumping of Na+ out of cells into blood in exchange for K+. * This pump causes a net movement of positive charge out of the cell (2 K+ in, for every 3 Na+ out) creating an electrochemical gradient that also causes Na+ to enter the luminal (urine) side of the cell. Kidney tubular cells in different portions of the nephron have different luminal “systems” to allow this Na+ influx.

Question 26

The following are vasodilators in the renal system EXCEPT: A. Prostaglandins B. Kinins C. ADH D. ANP (atrial natriuretic peptide)

Answer 26

C. ADH Opposing the saline retention and vasoconstriction observed in stress states are the actions of atrial natriuretic peptide (ANP), nitric oxide, and the kidney prostaglandin system.

Question 27

The following are TREATMENT of TUR Syndrome except: A. Terminate the procedure as soon as possible B. Fluid restriction if Na is <120 mEq/L C. Obtain 12 lead ECG D. Discontinue Na if > 135 mEq/L E. Establish airway

Answer 27

D. Discontinue Na if >135 mEq/L * Treat severe symptoms (if serum Na+ <120 mEq/L) with 3% sodium chloride IV at a rate <100 mL/hr. * Discontinue 3% sodium chloride when serum Na+ >120 mEq/L

Question 28

The bladder is located in the retropubic space and receives its innervation from: A. T11 - T12 B. T10 - L1 C. T11 - L2

Answer 28

C. T11 - L2 Sympathetic nerves originating from **T11 to L2** The bladder is located in the retropubic space and receives its innervation from sympathetic nerves originating from T11 to L2, which conduct pain, touch, and temperature sensations.

Question 29

The best measure of of glomerular function: A. Urine output B. FENa C. GFR D. BUN

Answer 29

C. GFR

Question 30

The 30-day mortality of TURP is: A. 0.2% B. 10% C. 0.5% D. 15%

Answer 30

0.2%

Question 31

Sympathetic innervation of the KIDNEY is supplied by: A. Preganglionic fibers from T8 to L1 B. Postganglionic fibers from T10 to L2 C. Preganglionic fibers from T10 to L2 D. Postganglionic fibers thru S2-S4

Answer 31

A. Preganglionic fibers from T8 to L1 Sympathetic innervation is supplied by **preganglionic fibers from T8 to L1**. The Vagus nerve provides parasympathetic innervation to the kidney.

Question 32

Sodium-glucose co-transporter 2 inhibitors (SGLT2 inhibitors) is thought to have kidney protection. This is due to which of the following: A. lower glomerular capillary hypertension and hyperfiltration B. lower glomerular capillary hypertension and improved medullary oxygenation C. inhibition of the resorption of bicarbonate by the tubular cells, leading to retention of bicarbonate D. elevates blood plasma osmolality, resulting in enhanced flow of water from tissues.

Answer 32

A. lower glomerular capillary hypertension and hyperfiltration * SGLT2 inhibitors lower glomerular capillary hypertension and hyperfiltration leading to **improved cortical oxygenation** and **less tubular glucotoxicity** lower glomerular capillary hypertension and improved medullary oxygenation - It's the CORTICAL OXYGENATION that is being targeted not the medullary section of the glomeruli. Inhibition of the resorption of bicarbonate by the tubular cells, leading to retention of bicarbonate - This is carbonic anhydrase MOA elevates blood plasma osmolality, resulting in enhanced flow of water from tissues. - Mannitol MOA

Question 33

Which of the following is ACCURATE pertaining to RIFLE Criteria as a means of grading AKI? A. RISK means acute creatinine rise of 25% B. INJURY means acute creatinine rise of 75% C. ACUTE FAILURE means acute creatinine rise of 150% D. FAILURE means acute creatinine rise of 200%

Answer 33

D. FAILURE means acute creatinine rise of 200% The ADQI Group definition for critically ill patients grades AKI by: RISK - acute creatinine rise of 50% INJURY - acute creatinine rise of 100% FAILURE - acute creatinine rise of 200%

Question 34

Generally, the radiocontrast dye effects on renal function onset is after: A. 24 hrs B. 3 days C. 5 days D. 12 hrs

Answer 34

A. 24 hrs * Onset usually begins after 24 - 48 hours. PEAK: 3-5 Days

Question 35

Which of the following physiologic response in CO2 pneumoperitoneum in the TRENDELENBURG position is ACCURATELY described: A. Inhibition of RAS system B. Decrease in SVR C. Decrease in MAP D. Increase in splanchnic flow E. Respiratory Acidosis

Answer 35

E. Respiratory Acidosis The following are the MAJOR hemodynamic changes during TRENDELENDBURG position: Cardiac: Increase SVR, MAP, Myocardial O2 consumption Neuro: Increase ICP, CBF, IOP, Circulation: DECREASE renal, portal, and splanchnic flow Respiratory: Decrease FRC, VC, COMPLIANCE RESPIRATORY ACIDOSIS Renal: Activation of RAS

Question 36

Normal GFR (glomerular filtration rate) A. 90 - 140 ml/min B. 50 - 75 ml/min C. 100 - 150 mL/min

Answer 36

90 to 140 mL/min.

Question 37

In ESRD patients the protein binding of morphine is: A. Decreased B. Increased C. Not affected

Answer 37

A. Decreased Hence, the dosing must be decreased or avoided.

Question 38

Maneuvers to MINIMIZE fluid absorption during TUR procedure EXCEPT: A. Limiting resection time to < 1 hour B. suspending the irrigating fluid bag no more than 30 cm above the operating table at the beginning and 15 cm in the final stages of resection C. avoidance of hypotonic intravenous fluids D. Limiting resection time to < 30 mins

Answer 38

D. Limiting resection time to < 30 mins 1. Limiting resection time to **<1 hour** 2. suspending the irrigating fluid bag no more than **30 cm above** the operating table at the beginning and *15 cm in the final stages of resection.* 3. avoidance of hypotonic intravenous fluids and treatment of regional anesthesia-induced hypotension with judicious use of intravenous vasopressor agents rather than intravenous fluids should be considered.

Question 39

A 45 year old female was admitted at the PACU for a suspiciously low urine output. Her pelvic surgery due to bleeding ectopic pregnancy was otherwise uneventful. After 3 hours post-op, her urine out is <0.5 ml/kg/hr. What is the next step in the management? A. Refer to nephro service because this might be a case of AKI B. observe C. repeat creatinine stat D. start furosemide

Answer 39

B. observe Based on KDIGO, the following are the criteria for AKI: ****1. An increase in serum creatinine by** ≥0.3 mg/dL (≥26.5 μmol/L)** within 48 hours OR 2. increase in serum creatinine to ≥1.5 times baseline, which is known or presumed to have occurred within the **prior 7 days** OR 3. Urine volume **<0.5 mL/kg/hr for 6 hours**

Question 40

Aggressive treatment of TURP syndrome with HYPERTONIC saline would MOST likely result to: A. Central pontine myelinolysis B. Hemoglobinuria C. Hemolysis D. Acute Intravascular volume expansion

Answer 40

CENTRAL PONTINE MYELINOLYSIS This is due to the rapid increase of osmolality thereby resulting to excessive shrinkage of brain after rapid hydration with HYPEROSMOLAR solution.

Question 41

A 50 year old female was admitted at the PACU for a suspiciously low urine output. Her UO for the past 12 hours is ONLY 0.5 ml/kg/hr. Should RIFLE Criteria be used, the urine output of this patient is considered: A. Risk B. Injury C. Failure of Kidney function D. Loss of kidney function

Answer 41

B. Injury RIFLE Criteria includes three levels of renal dysfunction and two clinical outcomes. The degree of renal dysfunction are defined either by: 1. changes in Serum Crea or eGFR OR 2. Oliguria R - Risk of renal Dysfunction: Crea increased by 1.5 fold (GFR decreased by 25%) OR Urine Output less than 0.5ml/kg/hr for 6 hours. I - Injury to the kidney: Crea increased by 2 fold (GFR decreased by 50%) OR Urine output less than 0.5ml/kg/hr for 12 hours F - Failure of kidney function: Crea increased by 3 folds (GFR decreased by 75%), Crea > 4mg/dL OR Urine output less than 0.3ml/kg/hr for 24 hours or ANURIA for 12 hrs L -Loss of kidney function: persistend ARF needing renal replacement therapy for more than 4 weeks E - End stage kidney disease: Need for dialysis for more than 3 months

Question 42

You are inducting a 50 year old male for TURP. With no contraindication noted, you decided to perform neuraxial anesthesia. In an awake patient with regional block, which of the following is not clinically consistent with TUR Syndrome? A. Elevated systolic pressure B. Increase in Pulse pressure C. Bradycardia D. Sensorium changes E. Hypotension

Answer 42

E. Hypotension

Question 43

Which of the following NMB agents is ideal for patient with ESRD? A. Succinylcholine B. Rocorunium C. Pancorunium D. Cis-atracurium

Answer 43

Cis-atracurium or Atracurium * Cis-atracurium because of its negligible histamine release potential.

Question 44

How does KIDNEY react under stress:

Answer 44

The sympathetic nervous system reacts to trauma, shock, or pain by releasing norepinephrine, which acts much like angiotensin II on the renal arterioles. Norepinephrine also activates the renin–angiotensin– aldosterone system and causes ADH release. The net results are shift of blood flow from the cortex to the medulla --> avid sodium and water reabsorption --> Decreased urine output.

Question 45

GFR declines by 10% after: A. 30 years old B. 50 years old C. 18 years old D. 60 years old

Answer 45

A. 30 years old In general, GFR declines 10% per decade after age 30 and is approximately 10 mL/min higher in men than women.

Question 46

Distribution of RENAL BLOOD FLOW is highest in: A. Medullary B. Cortical C. no particular order

Answer 46

CORTICAL area

Question 47

A 55 year old male is scheduled for TURP procedure. You wanted suggest an irrigant that is LEAST likely attributed to the development of TURP syndrome. Which of the following would BEST fit your intraoperative concern? A. Glycine B. Distilled water C. Mannitol D. Sorbitol

Answer 47

A. Glycine

Question 48

TRUE or FALSE cis-Atracurium metabolism results in lower LAUDANOSINE blood levels than does of ATRACURIUM in ESRD patients.

Answer 48

TRUE Because cisatracurium is about 4 to 5 times as potent as atracurium, about 5 times less laudanosine is produced, and accumulation of this metabolite is not thought to be of any consequence in clinical practice. Unlike atracurium, cisatracurium in the clinical dose range does not cause histamine release Dictum: "The more potent, the less laudanosine."

Question 49

Bladder stretch sensation is transmitted via: A. Parasympathetic fibers from segments S2 to S4 B. Sympathetic fibers from segments S2 to S4 C. Parasympathetic fibers from segments S1 to S4 D. Sympathetic fibers from segments S1 to S4

Answer 49

A. **Parasympathetic** fibers from **segments S2 to S4** The bladder stretch sensation is transmitted via parasympathetic fibers from segments S2 to S4. Parasympathetics also provide the bladder with most of its motor innervation.

Question 50

At what spinal level does pain conduction of Testes is: A. T10 - L1 B. T12 - T10 C. T12 - L2 D. L2 - L5

Answer 50

T10-L1

Question 51

which of the following fresh gas flow can clinically prevent the significant production of free fluoride ions during general anesthesia? A. at least 2L/min B. at least 3L/min C. at least 4L/min D. at least 1L/min

Answer 51

A. at least 2L/min

Question 52

At what dermatomal level provides adequate anesthesia for TURBT and at the same time preventing OBTURATOR reflex: A. T9 B. T6 C. T8 D. T12

Answer 52

* T9-10

Question 53

This reflex pertains to an increase in arterial pressure which leads to afferent arteriolar wall stretching to constrict (by reflex).

Answer 53

Myogenic Reflex Theory The myogenic reflex theory holds that an increase in arterial pressure causes the afferent arteriolar wall to stretch and then constrict (by reflex); likewise, a decrease in arterial pressure causes reflex afferent arteriolar dilatation.

Question 54

A measurement of plasma creatinine concentration is inversely related to: A. Renal blood flow B. Renal plasma flow C. GFR (glomerular filtration rate) D. Filtration fraction E. Urea concentration

Answer 54

GFR GFR (glomerular filtration rate) Notably, serum creatinine does not usually rise significantly until GFR rates fall below 50 mL/min, so preoperative serum creatinine levels may fall within the normal range in patients even with some degree of existing kidney dysfunction. Creatinine concentration in the blood is inversely related to glomerular filtration rate (GFR). GFR is the amount of fluid that the kidney filters per unit time (mL/min). As a rule of thumb, If creatinine concentration doubles then GFR declines by 50%. Renal blood ow (RBF) is the amount of blood passing through the kidneys per unit time (~25% of total cardiac output or ~1 L/min)

Question 55

This kidney function test uses a spot sample of urine and blood to compare sodium and creatinine excretion:

Answer 55

Fractional excretion of sodium (FENa) This test can be useful to distinguish hypovolemia and kidney injury A value of above 1% is consistent with ATN (Acute Tubular Necrosis)