Anesthesia Principles and Practice I: Lecture 8 - Renal Flashcards

Question

Chronic Kidney Disease (CKD)

Answer 1

Chronic and progressive deterioration of renal function. Estimated GFR <60 ml/min A Decrease to <25 mL/min eventually progresses to end stage-renal disease (ESRD) Diabetes Mellitus and Undiagnosed Hypertension are biggest Risk Factors ~15% of Americans have CKD Approximately ½ our population will develop it at some point. Racial Disparities in CKD Risk is 3.6x higher for Black/African Americans 1.8x higher in Native American population 1.5x higher risk for Hispanics ## Footnote Genetic variables and disparity in access to healthcare is thought to underlie these differences in prevalence

Answer 2

Symptoms are often undetectable due to all the back up in the kidneys Renal reserve function may hide CKD until function is <10% of normal Renal ultrasound may help rule out obstructive disease/polycystic kidney disease CT- Gold standard for diagnosis of nephrolithiasis

Answer 3

Increase is Creatinine and Urea Not proportional to level of impairment Cr levels may remain within normal limits until 50%↓ in GFR Serum K+ concentration WNL until GFR approaches 10%... wont see till the kidneys are essentially failing Sodium Sodium levels remain intact until function is severely limited ## Footnote WNL = within normal limits

Answer 4

Cardiovascular Mortality from cardiac causes is 10X higher in CKD versus non-CKD patient Acute MI- 2-year mortality >70% in Dialysis Patients Hypotension non-responsive to volume replacement should be worked up for Cardiac Tamponade Immunologic- Infection is second leading cause after CV disease. Pulmonary/UTI common. Anemia- chronic anemia can lead to ↑Cardiac Output, Left Ventricle Hypertrophy, LV Dilation Uremic Bleeding- from impaired platelet function. Treatment includes DDAVP, conjugated estrogen, and Cryoprecipitate. Neurologic Mild issues include impaired abstract thinking, insomnia, irritability. Severe seizures, obtundation, uremic encephalopathy, coma

Answer 5

Patients that are hypertensive and hypervolemic despite diuretics/salt restriction Hemodialysis- Diffusion of solutes between blood and dialysis solution Removes metabolic waste Replenishes buffers Blood is heparinized to prevent clotting Countercurrent of dialysate flows across semi-permeable membrane. ~65% reduction in BUN Takes around 4 hours Annual mortality rate ~16%

Answer 6

<10% of all Dialysis Patients Plastic Catheter is anchored in the peritoneal cavity May be better for patients that cannot handle huge fluid shifts CHF Unstable Angina Peritonitis is a common and Serious complication Hospitalization rates are high than hemodialysis.

Answer 7

Hypotension- Most common side effect d/t ↓intravascular volume. Hypotension may Also be d/t Myocardial stunning/Ischemia Cardiac Dysrhythmias Pericardial Tamponade Air Embolism Antihypertensive medication Most hypotensive events can be managed by: Slowing ultrafiltration Reposition patient into T-berg ↑Venous return Admin of small saline boluses Exposure of Blood to foreign substances Dialysis reactions including anaphylaxis/anaphylactoid reactions Use of ACE inhibitors can predispose to these things ## Footnote Anaphylaxis is not dose dependent; Anaphylactoid is dose dependent (LOOK UP WHAT IG EACH ARE!!!)

Answer 8

Protein Energy Wasting Catabolism and anorexia beget lean muscle loss Fluid retention can mask this weight loss Dietary consultation and supplementation may be necessary ESRD Patient’s used to living with a higher potassium, so they can tolerate a higher potassium till signs are seen Cardiac and neuromuscular responses to hyperkalemia are less than in patient’s with normal renal function Infection a common cause of M&M

Answer 9

Make sure patient is optimized for surgery with timing of dialysis Prevent further kidney injury Common comorbidities in dialysis patients: Angina 17% Hx of MI 12% TIA/Stroke 11% Smoking 15% Diabetes 9% Malignancy 13% Anesthesia Meds That Require Significant Elimination by the Kidney: Thiopental (leathal injection) Pancuronium (Peds hearts) Atropine/Glycopyrrolate Edrophonium and Neostigmine Inotropes Hydralazine/Inotropes, Milrinone Aminoglycosides Cephalosporins Codeine, Meperidine, Morphine ## Footnote METs <4 (Walking a flight of stairs) should prompt cardiac workup

Answer 10

BP must be under control NO ACE/ARB on Day of Surgery Target glucose <180 mg/dL >5.5 mEq/L may result in delay of surgery Expect metabolic acidosis from persistently low bicarbonate levels Preop coagulopathy should be treated with DDAVP Ponder Gastric Aspiration Prophy, def with Diabetics H2 blockers are renally eliminated, adjust dose ## Footnote 1 unit of insulin drops blood glucose by 25 mg/dL

Answer 11

Arterial Access can help predict fluid response TEE may be needed to monitor hemodynamics Do not start PIV on limb with AV Fistula Avoid IV in nondominant arm if possible Avoid upper arm of dominant arm The vessels may ne needed for future AV grafts Femoral lines carry infection risk Dorsalis Pedis/Posterior Tibialis arterial access May be inconvenient with patient positioning Edema/Poor tissue perfusion may be an issue Arterial pressure and gases will NOT be accurate if placed in same limb as AV Fistula ## Footnote Not a good call to use Dialysis access catheters for fluid admin, may need to be used in a pinch. ALWAYS ASPIRATE HEPARIN out of these lines and reintroduce when discontinued

Answer 12

Hypotension on induction is very common RSI with sux if needed and K is <5.5 mg/dL Roc will have a very increased DOA ↓ Sympathetic Nervous System Activity impairs peripheral vasoconstriction Small volume changes, PPV, abrupt positioning changes, and med related depression of heart function can have marked effects This means you may have to treat hypotension very aggressively Do not be afraid to use stronger meds if Neo is "refractory" (Vasopressin/Levophed etc), maintaining end organ perfusion is your main focus ## Footnote I am quick to prepare a backup phenylephrine infusion for these patients.

Answer 13

Processed EEG (BIS etc) may assist in dosing maintenance infusions/volatile: You may be able to get away with less anesthesia but need to confirm patient is not aware. Hemodynamic instability is the norm Consider presurgery placement of defibrillator pads in high-risk patients Avoid or underdose NMBs: Slow excretion of vec and roc Atracurium and Cisatracurium do not depend on renal excretion Laudanosine is a product of Benzylisoquinolinium metabolism- potentially toxic systemic effects Renal Excretion ~50% for Neostigmine Sugammadex appears safe in CKD with creatinine clearance> 30 ml/min No current data under that level of kidney function Opioids can reduce VA dose and therefore their myocardial depressant tendencies. Remifentanil can be used safely ## Footnote Laudanosine can cross BBB and may cause excitement/seizures. Has effects at GABA, opioid, and nicotinic acetylcholine receptors

Answer 14

Patients with severe renal dysfunction w/o hemodialysis may benefit from preop hydration ~500 ml to increase urine output Risk of hyperchloremic metabolic acidosis w/ hyperkalemia with large NS resuscitation It is not recommended to use mannitol or Lasix to stim urine output if they are already hypovolumic May further damage kidneys Blood transfusions as needed to deliver oxygen carrying capacity

Answer 15

Brachial plexus blocks are useful Produces Vasodilation that may help surgical process Be Cognizant of the chance of platelet dysfunction and residual heparin effects if considering neuraxial anesthesia TAP/ESP blocks may help control post-op pain after abdominal surgery/kidney transplant and nephrectomy

Answer 16

Poor nutritional status makes these patient’s skin very prone to damage and bruising. These means pad boney prominences very well. Protect fistulas 100 percent Optimal positioning would allow for Fistula palpation to confirm patency Patient’s with ESRD should have dialysis within 24 hours of elective surgery Patients on peritoneal dialysis and having abdominal surgery undergo hemodialysis postop.

Answer 17

CKD Patient’s are high risk for periop MI, continuous post-op ECG is recommended. Hemodialysis 24 hours postop, after fluid shifts have settled. Multimodal analgesia is beneficial

Answer 18

Those who receive a transplant outlive those that remain on the transplant list by about 4 years. CV Disease and infection are most likely killers Live Donor Kidney- is preferred to deceased-donor kidneys. Kidney from Cadaver can be preserved up to 48 hours. Donor Kidney received perfusion from Iliac vessels Ureter is anastomosed to bladder.

Answer 19

Thymoglobulin- Antirejection drug admin over several hours. Side effects include chills, headache, abdominal pain Premed with Tylenol, corticosteroids, +/- antihistamines Methylprednisolone 7 mg/kg max 500 mg- usually given in the OR Prednisone Taper post op Tacrolimus rejection maintenance- usually started POD 1 General Anesthesia usually preferred to Epidural to control ventilation Surgical Retraction near the diaphragm can make breathing mechanics difficult. Mannitol admin is common after new kidney- prevents acute tubular necrosis by decreasing excess tissue and intravascular fluid. Upon release of renal vessel clamps- Hypotension is a possibility as vasodilators are released from that new kidney ”Renal Dose Dopamine”- Has largely been refuted. Dobutamine may be more appropriate Arterial lines are common to monitor global perfusion. ## Footnote Metabolic by products like lactate, etc.

Answer 20

Acute Immunologic Rejection- Can occur almost immediately after blood supply to the kidney is restored. Treatment- removal of kidney, definitely in the face of DIC Continue immunosuppressive therapy postop Tacrolimus- Calcineurin inhibitor Corticosteroid Hematoma formation- May arise in graft postop, potential for it to obstruct vessels. Opportunistic Infections- prolonged immunosuppression Frequency of Cancer- 30-100x higher in transplant recipients.

Answer 21

Most Stones are Calcium Oxalate (75%) can be d/t hyperparathyroidism. Stones in Renal Pelvis are usually painless Unless Infection or Obstruction is present Renal Stone passing into Ureter cause extreme flank pain, N/V, and hematuria. Obstruction of the ureter by a stone can cause renal failure How do we get them out? Extracorporeal Shock Wave Lithotripsy- brings risk of cardiac dysrhythmias d/t R on T Phenomenon. Ureteroscopy- Most common approach requiring Anesthesia ## Footnote Percutaneous removal of kidney stones may be necessary for stones >20mm and Staghorn (branching) calculus. This is carried out in the prone position.

Answer 22

Presents as acute oliguria in patients with decompensated cirrhosis. Occurs in 25-30% of patients in acute liver disease Treatment- re-establishing splachnic circulation with pressors (levophed/albumin etc) Albumin bolus 1g/kg up to 100g may be administered. Midodrine- alpha agonist given PO Octreotide- Somatostatin analogue This is a diagnosis of exclusion in chronic liver failure patients ## Footnote Liver failure, the kidneys start failing even with no structural damage

Answer 23

Presenting Symptom is generally disruption of urine flow Treatment- alpha adrenergic antagonists like terazosin, doxazosin, tamsulosin May cause orthostatic hypotension in some TURP- has been gold standard of treatment for many years, new technologies are presenting Photoselective Vaporization and Laser Enucleation Less blood loss, reduced irrigant needs, ↓hospital stay, ↓post-op catheter

Answer 24

Large volumes of nonconductive irrigation solution (glycine, mannitol, sorbitol) are used to remove tissue and prevent conduction of electrocautery to cause thermal injury Resorption of large volumes of fluid can cause hyponatremia Long resection time and height of irrigating fluids can ↑risk Shoulder pain during TURP under spinal may indicate surgeon has perforated the bladder ## Footnote If the bladder is perforated the patient may experience referred shoulder pain from diaphragmatic irritation.

Anesthesia Principles and Practice I: Lecture 8 - Renal Flashcards

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