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24 ANE 8509 Principles of Anesthesia I > Final- Anesthesia for Genitourinary Procedures (7/18/23) > Flashcards

Final- Anesthesia for Genitourinary Procedures (7/18/23) Flashcards

1
Q

Indications for Urological Surgery

A
  • Direct visualization of urethra, bladder, ureter, kidney
  • Biopsies/evaluate bleeding
  • Retrograde pyelography
  • Laser/retrieve stones
  • Remove/treat stricture
  • Resect masses
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2
Q

List the structures of the genitourinary system from the top to bottom.

A
  • Kidney
  • Ureter
  • Bladder
  • Urethra
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3
Q

What position will the patient be in for Urological Surgery?

A
  • Lithotomy
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4
Q

In the Lithotomy position, the stirrups can cause what type of nerve injury?

A
  • Peroneal Nerve Injury
  • Femoral Nerve Injury
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5
Q

What other problems can occur besides nerve injuries in the Lithotomy position?

A
  • Skin breakdown d/t stirrup pressure
  • Hip dislocation
  • Back strains
  • Vessel compression (DVT, Compartment Syndrome, Venous Pooling)

Remember to move both legs simultaneously to prevent torsion and injury to lower spine

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6
Q

What lab is the best measure of glomerular function?

A
  • GFR
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7
Q

What is normal GFR?
When will patients become symptomatic?

A
  • 125 mL/min
  • Asymptomatic until a 50% drop
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8
Q

What will be the result of moderate GFR insufficiency?

A
  • ↑ BUN/Creat
  • Anemia
  • Decreased energy
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9
Q

What will be the result of severe GFR insufficiency?

A
  • Profound uremia (high levels of waste product in the blood)
  • Acidemia
  • Volume overload
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10
Q

What is BUN?

A
  • Blood Urea Nitrogen
  • BUN measures the amount of nitrogen in the blood that comes from the waste product urea.
  • Urea is produced when the body breaks down proteins from the food we eat.
  • The liver then processes this nitrogen into urea, which is eventually eliminated from the body through urine.
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11
Q

What is a Normal BUN?

A
  • 8-18 mg/ dL
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12
Q

What will influence the BUN level?

A
  • Exercise
  • Steroids
  • Dehydration
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13
Q

BUN will not be elevated in the kidney disease until GFR is ________% of normal.

A
  • 75%
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14
Q

What is Creatinine?

A
  • Creatinine is a waste product that comes from muscle metabolism.
  • It is produced at a relatively constant rate and is filtered out of the blood by the kidneys, then excreted through urine.
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15
Q

What is normal Creatinine?

A
  • 0.8 - 1.2 mg/dL
  • Varies with age and gender
  • Higher in men d/t more muscle mass
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16
Q

What are the considerations during the preoperative evaluations of patients with Chronic Renal Failure?

A
  • Hypervolemia (↑Na, ↑H2O)
  • Acidosis (↓ production of ammonia, ↑ Anion Gap)
  • Hyperkalemia (may live @ an elevated K+ level)
  • HTN d/t RAAS
  • Cardiac/Pulmonary Symptoms
  • Hematologic Symptoms
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17
Q

Because most anesthetic drugs are lipid soluble in a non-ionized state, termination doesn’t depend on _________.

A
  • Renal Excretion

Metabolite of these drugs are excreted as water-soluble compounds

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18
Q

What are drugs of concern for patients with Renal Insufficiency?

A
  • Drugs that are highly ionized and eliminated unchanged in urine
  • Muscle relaxants
  • Cholinesterase inhibitors (neostigmine)
  • Thiazide diuretics
  • Digoxin
  • Many antibiotics
  • Active metabolites of opioids (morphine/meperidine)
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19
Q

What is the active metabolite of morphine?

A
  • Morphine-6-glucuronide
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20
Q

What are examples of endoscopic evaluations (scope procedures) of the lower urinary tract?

A
  • Through urethra (urethroscopy)
  • Through bladder (cystoscopy)
  • Through ureteral orifice (ureteroscopy)
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21
Q

What are the two types of scopes used for urological procedures?

A
  • Flexible
  • Rigid (this scope to the ureter, it will stop in the bladder)

Scope hooked to irrigation system
Guid Wire is inserted through scope for catheter and instruments

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22
Q

Purpose of a urethroscopy/cystoscope.

A
  • Visualize the urethra and/or bladder d/t urinary symptoms (Pain, burning, hematuria, difficult urination.)
  • Diagnose and Treat a lesion or stricture (dilate stricture, treat cystitis, stent placement, resect tumors).
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23
Q

The procedure of choice for mid/distal ureter or bilateral stones.

A
  • Ureteroscopy (flexible scope)

Can incorporate laser technology

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24
Q

What percentage of men and women lifetime will experience ureter stones?

What is the recurrence percentage?

A
  • Men: 10%
  • Women: 5%
  • Recurrence: 50%
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25
Q

Ureter stones are diagnosed using _______, _______, and ________.

A
  • CT
  • KUB X-RAY
  • IVP (Intravenous Pyelogram)
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26
Q

Complications of ureteroscopy are low.
What is the percentage for perforation?
What is the percentage of stricture formation?

A
  • Perforation: 5%
  • Stricture formation: <2%
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27
Q

What are some medical therapy for ureter stones?

A
  • MET (Medical Expulsive Therapy)
  • NSAIDs
  • Aggressive Fluid intake (↑ Water, ↑ Cranberry Juice)
  • CCB and alpha blockers to vasodilate
  • Surgery/ Procedures
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28
Q

What are the choices for surgery/procedure for ureter stones?

A
  • Stone basket vs. Laser (preferred)
  • Shock Wave Lithotripsy
  • Percutaneous nephrolithotomy (least preferable)
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29
Q

Shock wave Lithotripsy is best suited for __________ intranephric stones.

A
  • small/medium
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30
Q

What is the risk for Shock Wave Lithotripsy (SWL)?

A
  • Risk of kidney injury or sub-capsular hematoma
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31
Q

Compare the Old SWL vs New SWL.

A
  • Old SWL: Water baths, hypothermia, painful
  • New SWL: Water-filled coupler device, focus beam, decrease pressure pulse, less painful
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32
Q

What are ABSOLUTE contraindications to SWL?

A
  • Bleeding disorder/ anticoagulants
  • Pregnancy (we do not thump babies)

Relative contraindications: Large calcified aortic/renal aneurysm, untreated UTI, Obstruction distal to renal calculi, Pacemaker, ICD, neurostimulator, Morbid Obesity.

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33
Q

Preoperative anesthetic considerations for SWL, stone basket, or laser therapy.

A
  • Single PIV
  • Consider anxiolytics
  • Appropriate ABX within 1 hour “cut time”
  • Iodine Allergy
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34
Q

Intraoperative anesthetic considerations for SWL, stone basket, or laser therapy.

A
  • Local vs. General (most people will be general)
  • LMA vs ETT
  • Minimal narcotics
  • Consider antiemeticc
  • Eye covering for laser (document!)
  • Lead for providers (cover breast, thyroid, sex organs, corneas)
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35
Q

What procedure will be indicated for large intranephric stone removal?

A
  • Percutaneous Nephrolithotomy
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36
Q

Describe a percutaneous nephrolithotomy.

A
  • Minimally-invasive procedure to remove stones from the kidney by a small puncture wound through the skin.
  • The procedure will require initial stent placement of ureteral stents to prevent obstruction as the fragment passes
  • Uses more fluoroscopy
  • Transurethral Resection syndrome possible
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37
Q

Preoperative anesthetic considerations for percutaneous nephrolithotomy.

A
  • Single PIV
  • Consider anxiolytics
  • Appropriate ABX within 1 hour “cut time”
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38
Q

Intraoperative anesthetic considerations for percutaneous nephrolithotomy.

A
  • General ETT
  • Short NMBD’s
  • Lateral position (bean bag, pillows)
  • Lead apron for provider
  • Eye covering for laser (document!)
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39
Q

What is an orchiectomy?

A
  • Orchiectomy is a surgical procedure in which one or both testicles are removed.
  • Almost always bilateral
  • Spermatic cord is clamped, cut, and sutured
  • Usually in younger males with tumor or metastatic prostate cancer.
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40
Q

What is a Hydrocelectomy?

A
  • Hydrocelectomy is surgery to remove a hydrocele.
  • A hydrocele is a fluid-filled sac inside the scrotum.
  • Wall of hydrocele excised and edges sutured to prevent recurrence.
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41
Q

Testicular torsion must be performed within ______ hours to prevent irreversible ischemia.

A
  • 6 hours
42
Q

What are the reasons for circumcision in older males?

A
  • Phimosis (tight foreskin)
  • Penile/ prostate cancer risk
43
Q

What is hypospadias?

A
  • Birth defect in boys in which the opening of the urethra is not located at the tip of the penis.
44
Q

What is a Penectomy?

A
  • Removal of squamous cell carcinoma on the penis or inguinal lymph node.
45
Q

What population group would seek a penile prosthesis discussed in the lecture?

A
  • Diabetic patients
  • Spinal cord injury patients
46
Q

Anesthetic considerations for scrotal and penile operations.

A
  • Preop anxiolytics
  • General: ETT vs LMA
  • Supine
  • Penile Block (S2-S4)
  • SCIP (take care with prosthesis touching skin before insertion)
  • Manipulation of genitals —vagal bradycardia, have glycopyrrolate ready
47
Q

What is a Cystectomy?

A
  • Surgical removal of all or part of the urinary bladder.
48
Q

What are the indications for cystectomy?

A
  • Simple-benign conditions (hemorrhagic cystitis, radiation cystitis)
  • Radical - malignant conditions (bladder cancer, includes removal of ureters, prostate, uterus, ovaries)
  • Requires ileal conduit or bladder substitution
49
Q

Preoperative anesthetic considerations for cystectomy.

A
  • Risk factors for CAD or pulmonary disease, CXR? (older patients)
  • Anticoagulant use. EKG?
  • Bowel prep
50
Q

Intraoperative anesthetic considerations for cystectomy.

A
  • GETA, SAB, epidural
  • Supine
  • SCIP
51
Q

What are common complications of cystectomy?

A
  • Blood loss: up to 3L (1-2 PIV, type and crossmatch blood)
  • 3rd space losses d/t open belly
  • Hypothermia (Use Bair Hugger or underbody water blankets)
52
Q

What is a TURP?

A
  • Transurethral Resection of Prostate
  • Surgical procedure that involves cutting away a section of the prostate using a laser or electrocautery.
  • Usually done on elderly patients to treat BPH, the gold standard
53
Q

What is the estimated blood loss of a TURP?

A
  • 2-4 ml/min
54
Q

What comorbidities will patients receiving a TURP procedure have?

A
  • Patients are generally in their 30-50’s
  • Obesity
  • HTN
  • Hyperparathyroidism
  • Chronic Renal Insufficiency
  • DM
  • Paraplegia
55
Q

Preoperative anesthetic considerations for TURP?

A
  • Consider comorbidities
  • Consider if the patient is on anticoagulants
  • Large bore IV (18G or 16G)
56
Q

Intraoperative anesthetic considerations for TURP?

A
  • General/ SAB (textbook: perform a SAB)
  • Lithotomy
  • Possible transfusion
  • TUR syndrome

The reason why you want to perform a SAB for a TURP is to assess for TUR Syndrome. You can assess when a patient begins to become confused versus being under general anesthesia.

57
Q

What are anesthetic considerations to take into account for robotic prostatectomy?

A
  • Insertion of an arterial line (we want to watch the blood pressure d/t to lack of fluid).
  • Phenylephrine drip
  • LIMIT IV fluids
58
Q

What is TUR syndrome?

A
  • Symptoms r/t hypervolemic water intoxication
  • Excessive volume expansion through venous sinuses
  • Hyponatremia
59
Q

What are CNS and EKG changes with a serum Na+ level of 120 mEq/L?

A

CNS changes: Confusion, Restlessness
EKG changes: Widening of QRS

60
Q

What are CNS and EKG changes with a serum Na+ level of 115 mEq/L?

A

CNS changes: Somnolence, Sleepy, Nausea
EKG changes: Elevated ST segments, Widened QRS

61
Q

What are CNS and EKG changes with a serum Na+ level of 110 mEq/L?

A

CNS changes: Seizure, Coma, Death
EKG changes: V-tach, V-fib

62
Q

What are the types of irrigants used in TURP?

A
  • Saline- volume overload, current dispersion with monopolar cautery
  • Glycine- metabolized in liver to ammonia
  • Water- intravascular hemolysis
  • Sorbitol- metabolized to CO2 and fructose, volume overload
63
Q

What is the irrigation rate for a TURP?
What is the absorption rate of irrigation fluid for a TURP?

A
  • Irrigation rate: 300 ml/min
  • Absorption rate: 20 to 200 ml/min
64
Q

Greater than _______ (volume) of irrigation fluid absorption is usually required for TUR syndrome.

A
  • Greater than 2 Liters
65
Q

How do you prevent TUR syndrome?

A
  • Limit resection time to 1 hour
  • Suspend the irrigation fluid less than 30 cm above the table
  • Treat hypotension for SAB with vasopressors NOT IVF.
66
Q

Treatment of TUR Syndrome (Mild vs Severe)

A
  • ABC’s
  • Stop the procedure
  • Consider invasive lines…for cardiovascular instability
  • For Mild symptoms (Na > 120): Fluid restriction and Loop diuretics
  • Severe symptoms (Na < 120): 3% IV saline
67
Q

What is a nephrectomy?

A
  • Surgical removal of a kidney, performed to treat several kidney diseases.
68
Q

How many nephrectomies are performed each year?
Complication rate?

A
  • 50,000 nephrectomies/yr
  • 20% post-op compilation rate: mortality, peritonitis, acute renal failure, etc.
69
Q

What are the types of nephrectomy procedures?

A
  • Simple: Irreversible non-malignant disease (autoimmune), trauma, congenital disease (Polycystic Kidney disease)
  • Radical: Renal cell carcinoma, kidneys and adrenal glands removed
  • Donor
70
Q

Nephrectomies are commonly associated with these conditions.

A
  • CAD
  • CRI/ESRD
  • HTN
71
Q

Preoperative anesthetic considerations for nephrectomy.

A
  • Anxiolytics
  • SCIP
  • Type/Screen or Type/Cross
  • 2 large bore IV
72
Q

Intraoperative anesthetic considerations for nephrectomy.

A
  • GETA: avoid nitrous
  • Consider an arterial line
  • Consider a central line: Ipsilateral to the surgical site
  • Consider regional anesthesia for postop pain
  • Have these items available: Colloids, Blood, Rapid transfusion set up, mannitol, furosemide
73
Q

Which kidney has a long ureter and longer vascular supply?

A
  • Left Kidney
74
Q

What arteries and veins do transplanted kidneys attach to?

A
  • Transplanted kidneys are attached to the common iliac vein and artery
75
Q

Do you re-anastomose the vein, artery, or ureter first in a kidney transplant?

A
  • Re-anastomose the vein first, then the artery, then the ureter.
76
Q

What fraction of all nephrectomies are living donor nephrectomies?

A
  • one-third
77
Q

What are the benefits of receiving a kidney from a living donor?

A
  • No physiological alterations compared to Donations after brain death or cardiac death donor.
  • Waiting times avoided
  • Decreases cold ischemic times
78
Q

What are the parameters of being a living donor?

A
  • Healthy
  • Two Kidneys
  • No DM, HIV, Liver Disease, Cancer
79
Q

Anesthesia Considerations for the Living Kidney Transplantation.

A
  • Similar to simple nephrectomy (anesthesia-wise)
  • Starts a couple of hours before recipient
  • Left kidney preferred
  • Aggressive isotonic hydration (10-20 ml/kg/hr)
  • Kidney needs low-level anticoagulation (5000 U of heparin)
  • Need diuresis
  • Furosemide, mannitol to maintain 2 ml/kg/hr
  • Protamine reversal (50 mg)
80
Q

What neurological instability will occur with brain death?

A
  • Cushing’s sign: HTN, bradycardia, wide pulse pressure
  • Catastrophic ICP elevation
81
Q

What cardiac instability will occur with brain death?

A
  • Massive release of catecholamines
  • Acute MI (40% occurrence)
  • Cardiovascular collapse (catecholamines run out, massive dilation)
82
Q

What pulmonary instability will occur with brain death?

A
  • Neurogenic pulmonary edema
  • SIRS
83
Q

What metabolic instability will occur with brain death?

A
  • Dysfunction of the hypothalamus and pituitary systems
  • Thermoregulation, hormones, insulin, electrolytes, DIC
84
Q

Anesthesia Considerations for the Cadaver Donors.

A
  • Don’t need anesthetic….need stabilization until retrieval
  • Maintain hemodynamics with short-acting agents
  • Significant bradycardia not responsive to anticholinergics…use isuprel
  • Fluid resuscitation with crystalloids and PRBC’s
  • Avoid glucose-containing solutions, can metabolize and become a hypotonic solution
  • PEEP/lung protective ventilation: 6-8 ml/kg of ideal body weight and 5-10cm PEEP
  • Steroids to attenuate immune response (in recipient)
85
Q

Donor Management Goals:
CVP

A
  • 4-10 mmHg
  • 6-8 mmHg for lung transplant
86
Q

Donor Management Goals:
MAP

A
  • 60-120 mmHg
87
Q

Donor Management Goals:
PaO2

A
  • > 300 mmHg on 5cm PEEP on 100% O2
88
Q

Donor Management Goals:
PaCO2

A
  • 35-45 mmHg
89
Q

Donor Management Goals:
ABG pH

A
  • 7.35-7.45
90
Q

Donor Management Goals:
Urine Output

A
  • Greater than 1 mL/kg/hr
91
Q

Donor Management Goals:
Sodium

A
  • 135-160 mEq/L
92
Q

Donor Management Goals:
Glucose

A
  • less than 150
93
Q

Donor Management Goals:
Ejection Fraction

A
  • > 50%
94
Q

Donor Management Goals:
Hemoglobin

A
  • > 9
95
Q

Ischemic time for kidney

A
  • 48-72 hours
96
Q

What happens to the donor kidney during ischemia?

A
  • Lack of O2
  • Depletion of ATP/glycogen
  • Failure of Na/K Pump
  • Increase intracellular sodium….edema
97
Q

What are preop evaluations for the kidney recipient?

A
  • Need to know last dialysis and K+ level
  • Diabetic (blood sugar, insulin)
  • 40% have CAD, and most have HTN (EKG, Heart Cath)
  • If PCKD, is nephrectomy concurrent? (Consider positioning)
98
Q

Intraoperative consideration for kidney transplantation.

A
  • GETA, may use Anectine if K+ appropriate
  • Consider cisatracurium
  • Supine; watch AV access
  • CVP/art line…..STERILE. Pt will be on immunosuppressants.
  • Donor anastomoses to recipient (vein, artery, ureter)
  • Steroids, mannitol, lasix, bumex, antithymocyte, albumin
  • Extubate on table…to ICU (D/C next day)
99
Q

What is an anti-thymocyte?

A
  • Infusion of rabbit-derived antibodies against human T cells to prevent/treat acute rejection
100
Q

What is the side effect of an anti-thymocyte?
Treatment?

A
  • Cytokine release syndrome: high-grade fevers (over 39C), chills, and possibly rigors.
  • Treatment: steroids (normally methylprednisolone), diphenhydramine 25–50 mg, acetaminophen 650 mg

24 ANE 8509 Principles of Anesthesia I (27 decks)

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