GU - Exam 6 Flashcards
(220 cards)
1
Q
Which kidney rests lower, why?
A
right kidney, hepatic displacement
2
Q
What holds kidneys in place?
A
-large vessels
-renal fascia
3
Q
Most outer aspects of kidney are convex, which is oncave?
A
medial margin due to the hilus
4
Q
Inner medulla of kidney has _ - _ pyramids
A
8-18
5
Q
Renal pyramids have striations, why?
A
loops of henle and collection ducts of nephrons
6
Q
Three buffering systems in the body:
A
respiratory system
renal system
protein buffers
7
Q
Where is the nephron located? Where does it begin and end?
A
partly in renal cortex and partly in medulla
begins: cortex at the glomerulus
ends: where tubule joins collection duct at papilla
8
Q
The glomerulus is a tuft of _ derived from the _ arteriole
A
capillaries
afferent
-blood comes to nephron via afferent arteriole and what isn’t sent into nephron to get filtered gets sent to efferent arteriole back to systemic circ.
9
Q
Flow of filtrate :
1. Into the _, then into the _ capsule
2. From there, into tortuous path in _ _ tubule
3. Then to the _ of _, then the _ _ tubule, then the _ _.
A
Glomerulus -> Bowman Capsule -> Prox Conv. tubule -> Loop of Henle -> Distal. Conv tubule-> collection duct
10
Q
Renal cortex contains which structures?
A
-Bowman capsule
-glomerulus
-prox and distal conv. tubules
11
Q
Which part of loop of Henle comes from proximal tubule towards pyramid, which part joins the distal tubule?
A
proximal tubule -> descending loop ->pyramid
ascending loop -> distal tubule
12
Q
2 kinds of nephrons and where they go?
A
Cortical nephrons: only partly into the medulla
Juxtamedullary nephrons: sit deep in cortex, extend deep into medulla
13
Q
_ nephrons comprise 1/5 to 1/3 of total nephrons and concentrate urine
A
Juxtamedullary
14
Q
Which direction is the blood (relative to the gloremulus) for the afferent and efferent arterioles?
A
Afferent into the gloremulus
efferent out of the gloremulus
15
Q
Where does oxygenation of the medulla (kidney) occur?
A
ascending loop of henle
16
Q
Two main functions of the kidney
A
- Excrete end products of metabolism
- Control concentration of the body fluids
17
Q
What happens in the medulla of the kidney?
A
urine creation
18
Q
What happens in the cortex of the kidney?
A
blood flow thru kidney
19
Q
What is the pathway of renal blood flow?
A
renal artery
segmental a.
interlobar a.
arcuate a.
interlobular
afferent arterioles
glomerular capillaries
efferent arterioles
peritubular capillaries + vasa recta interlobular vein
arcuate v.
interlobar v.
segmental v.
renal vein
20
Q
Kidneys are highly vascular, receiving _ - _ L of blood /min or _ - _ % of the CO
A
1.1-1.2 L/min flow
20-25% of CO
21
Q
T/F O2 gets removed in glomerulus
A
false
22
Q
CO portion that goes thru kidney is called the _ _ and normal value for that is between _ and _ %
A
renal fraction
20-25%
23
Q
Which receives more blood from renal blood flow, cortex or medulla?
A
cortex
24
Q
Renal Blood Flow equation:
A
RBF = Renal plasma flow (RPF) / (1-Hct)
25
What regulated renal blood flow?
-intrinsic autoreg (**afferent arteriole dilation and myogenic mechanisms control this**)
-neural reg
26
At which MAP ranges is renal blood flow unaffected?
50-180mmHg
- if <50, filtration ceases
27
Renal blood flow and GFR have a _ relationship
direct
-one increases or decreases, so does the other
-GFR reduces = dilation of afferent arteriole
-increased blood flow = GFR increases
28
Which affects renal blood flow more, SNS or PNS?
SNS, and it gets overruled easily via autoreg
**PNS doesn't affect renal blood flow at all**
29
Homeostasis is maintained with kidneys via 3 mechanisms
-filtration
-reabsorption
-tubular secretion
30
Filtration fraction is the amount of renal plasma flow that becomes filtrate and is equal to _ / flow of 1 kidney.
GFR
31
Normal GFR, normal flow to one kidney=
GFR = 125mL/min
1 kidney = 650mL/min
filtration fraction = 125/650 = ~19% of plasma flow
32
Glomerulus produces _ -free filtrate, of which, _ % is reabsorbed by the renal tubules and the other percent is eliminated as urine.
protein -free
99% is reabsorbed
33
GFR depends on:
-pressure of glomerular capillaries (60mmHg)
-pressure of bowman capsule (18mmmHg)
-colloid osmotic pressure of plasma protein (28mmHg)
34
Filtration pressure formula:
= capillary pressure (60) - Bowman (18) - oncotic pressure (28)
Normal =~10mmHg (I know math ain't mathin', just know 10)
35
What structure regulates GFR?
juxtaglomerular complex
-allows fluid in the distal tubule to change the tone of afferent and efferent arterioles and change GFR
-sits in macula densa, affects many arterioles
36
Increase or Decrease GFR:
INCREASE:
-blood flow
-arteriole dilation
-increased resistance in efferent arteriole
DECREASE:
-afferent arteriole constriction
-efferent arteriole dilation
37
What are the cells of the afferent and efferent arterioles called in the juxtaglomerular apparatus? What do they contain?
Juxtaglomerular cells (smooth muscle cells)
-contain renin
38
Autoreg process in face of decreased GFR:
1. GFR is decreased and there is overabsorption of of Na and Cl so less in _ tubule
2. _ _ senses this fluid change
3. Afferent arterioles _ and jxa release _
4. _ initiates _ system and increases _ (liver->lung)
5. _ causes vasoconstriction and _ is secreted.
6. _ increases reabsorption of Na and H2O, _ volume in body, increasing pressure in _ and GFR to become normal again
1. distal
2. macula densa
3. dilate, renin
4. renin, RAAS, angiotensin II
5. Angiotensin II, aldosterone
6. Aldosterone, increasing, glomerulus
39
Glomerular capillary has many _ charged pores that are _ - _ nm in size. Substances larger than _ nm and that are not _ charged are easily filtered.
negatively
70-100nm
>80nm negatively
40
The glomerulus is highly permeable to almost everything except _ _.
plasma proteins
-glomerular filtrate is almost exactly like plasma but without the protein component
41
What is the primary function of the proximal tubule?
Active (1*) Sodium transport
-Water and other solutes follow as a result of cotransport
-Hydrogen and Cl secretion in exchange for Na and H2O reabsorption also happens
-Electrolyte (K, Ca, PO4, uric acid, HCO3, reabsorption also happens)
-other things like glucose, AA, vitamins, and proteins are reabsorbed too
42
What are the primary functions of the three parts of the loop of henle?
Thin (descending) - water
Thin (ascending) - Na/Cl
Thick (ascending) - Na/Cl
-All three help establish and maintain hyperosmotic gradient of the medulla to conserve Na and H2O
-blood flow slows a bit in macula densa, helping maintain gradient
43
What are the primary functions of the early distal tubule?
Absorbs Na, Cl, K
-Not water
-Location of action thiazide diuretics
Location of macula densa
Makes final adjustments on urine pH, osmolality, and ionic composition
44
Functions of the late distal tubule
1. Reabsorbs sodium (with aldosterone)
2. Secrete potassium (for sodium)
3. Secrete hydrogen ions against the concentration gradient-helps regulate acid/base
4. Reabsorbs water (with ADH)
45
Collecting duct functions:
-water permeability is controlled by ADH to determine urine conc.
-when present, ADH makes it reduce urine volume and sends water to be reabsorbed in the medullary interstitium
-also secretes some H+ so controls acid/base levels to an extent
46
Any condition that causes amount of O2 transported to tissues to _ stimulates the release of _ from the kidneys to produce RBC and correct _.
decrease
erythropoietin
hypoxia
-when both kidneys are destroyed by renal disease -> anemia
47
Kidneys secrete:
-renin
-H+
-K+
-erythropoietin
48
Aldosterone
-Produced
-Released
-Renal effects
Produced: Adrenal cortex
Released: adrenal cortex
Renal effects: distal convoluted tubule (H2O and sodium)
49
ADH
-Produced
-Released
-Renal effects
Produced: hypothalamus
Released: neural hypophysis, posterior pituitary
Renal effects: Promotes reabsorption of H2O, increases tubular permeability in distal tubule
50
Angiotensin
-Produced
-Released
-Renal effects
Produced: Liver (angiotensinogen)
Released by: Kidneys
Renal effect: angiotensin II (vasoconstriction)
51
ANF
-Produced
-Released
-Renal effects
Produced: Cardiac atria
Released by: Cardiac atria
Renal effects: Inhibits Na+, H2O reabsorption in kidney, enhances renal flow and GFR
52
Which factors have largest impact on aldosterone release?
K level in extracellular fluid > RAAS > Na level in extracellular fluid
53
ADH is inhibited by stretch of _ _
atrial baroreceptors
54
Stimulation of renin release includes:
-beta adrenergic stim
-decreased perfusion to afferent arterioles
-decrease Na delivery to distal tubules
55
ANF antagonizes effects and secretion of:
renin
aldosterone
ADH
-works as strong diuretic, produces dose dependent decrease in BP
56
Calcium metabolism is influenced by 3 things:
-vit D
-PTH
-calcitonin
57
Vit D is obtained in which 2 ways:
-diet
-conversion from UV radiation via cholesterol in skin
58
Vid D is activated in 2 places:
-1st in kidneys (cholecalciferol - > 25-hydroycholecalciferol)
-liver (-> 1,25-dihydroxycholecalciferol)
59
How do prostaglandins like PGE2 and thromboxane A impact renal excretion?
PGE2 = vasodilator
thromboxane A = contracts vasc smooth musc
60
Which substances are secreted via countertransport in the kidney?
**Hydrogen**
**Potassium**
Urate
61
Which renal arteriole does angiotensin II constrict
Efferent
62
How are proteins reabsorbed in the kidney?
Pinocytosis
63
ADH release trigger? inhibitor?
1. Osmoreceptors located near hypothalamus stimulates release
2. Stretch of atrial baroreceptors inhibits ADH
64
What is the apex of the medullary pyramid called?
papilla
65
What is the magnitude of the decrease of renal function related to in regional anesthesia?
Degree of sympathetic blockade and BP depression
66
What happens at high levels of SAB (renally)?
impaired venous return
diminished CO
reduced renal perfusion
67
Thoracic levels of epidural cause what changes renally?
Moderate reduction in RBF and GFR ONLY if epi is used with LA
68
What relationship does Cr have to GFR?
inverse
69
What does high BUN tell us regarding pathophysiology?
uremia
70
High BUN, normal Cr (extrarenal or renal)?
extrarenal cause
71
High BUN, high Cr (extrarenal or renal)?
renal cause
72
Creatinine clearance levels and kidney function
-mild
-moderate
-dialysis
1. <50
2. <25
3. <10
73
BUN relation to GFR
inverse
74
BUN
-What is it?
-Normal range
-What is it affected by?
-Best indicator of?
-Early/late indicator of renal disease?
End product of protein metabolism
**10-20 mg/dL**
Altered by state of hydration, muscle wasting, GFR
-Best way of dx urea levels in the body
-LATE indicator of renal disease
75
When does BUN increase (relative to GFR)?
GFR reduced by 50%
76
Creatinine
-What is it?
-Eliminated by?
-What is it used for (measurement)?
-Range
1. Product of creatin metabolism
2. Glomerular filtration (almost entirely)
3. Marker of glomerular filtration
4. **0.7-1.5mg/dL**
77
What is the normal ratio of BUN/Cr?
10:1
-Increases with hypovolemia
78
Creatinine Clearance
-What does it measure?
-How to do it?
-Normal range?
Measures ability of the glomeruli to excrete urine
Most reliable assessment tool for renal function
24 hour urine
**95-150mL/min**
79
What effect do general anesthetics have on the renal system?
RBF, GFR UO and electrolyte secretion decreased
80
What effects do catecholamines have on the renal system?
Decrease renal perfusion and increase renal vascular resistance
81
Des and sevo effect on renal system
Decrease CO and SVR -> decreased perfusion pressure -> increased renal vascular resistance -> decreased RBF
82
Sevoflurane (specific) effects on kidney
Accumulation of fluoride ions, but not nephrotoxic
83
Opioids and nitrous effects on renal
Same as volatile
Decreased CO and SVR --> decreased perfusion pressure --> increased renal vascular resistance -> decreased RBF
84
Structures that release H+ into tubular fluid:
-epithelial cells of prox tubule
-thick part of loop of henle
-distal tubules
-collection ducts
85
Acid and base balance begins in _ _ by forming _ _ from carbonic anhydrase reacting CO2 with H2O. H2CO3 becomes HCO3 and H+, sending H+ to tubular fluid in exchange for _
epithelial cells
carbonic acid H2CO3
Na+
86
What happens during alkalosis if filtered amount of HCO3 > H+ secreted?
-extra HCO3 reacts with H+ and is absorbed as CO2 into ECF. Remaining extra HCO3 is lost with Na+ as urine
87
What happens during acidosis when H+ > HCO3 in tubules?
combines with phosphate buffers or NH3 and is peed out
88
Phosphate buffer system includes which 2 components?
HPO2- (monohydrogen phosphate)
H2PO4 (dihydrogen phosphate)
-both are poorly reabsorbed and concentrate in tubular fluid.
89
Which component is more concentrated in phosphate buffer system, HPO2- or H2PO4?
HPO2-
90
How does phosphate buffer system work?
-Extra H+ in ECF enters tubule + links with HPO2- to make H2PO4 which gets peed out.
-Na+ is traded for H+ and links with HCO3- before entering ECF, making sodium bicarb increasing plasma pH.
91
How does NH3- help improve acidosis?
-it is secreted into tubules and combines with H+ to make NH4 and gets peed out with Cl - and other anions
92
All renal epithelial cells produce NH33 EXCEPT
THIN part of loop of Henle
93
T/F To fix acidosis, the renal system causes one to urinate basic urine.
false. Acidic urine in response to acidosis and alkalotic urine with alkalosis
94
T/F Compound A and inorganic fl ions are nephrotoxic
true
95
T/F Current anesthetic tools/agents, when used properly, are nephrotoxic
false
-only agent known to be nephrotoxic directly is methoxyflurane - not used
96
S/S fluoride nephrotoxicity=
-polyuria, hypernatremia, serum hyperosmolality, elevated UN and creatinine, decreased ClCr
97
Compound A formation factors:
-high conc agent
-high temp in CO2 absorber
-low FGF
-high states of CO2 production
-absorbents with strong base activators like Na or K hydroxide (soda lime)
98
Which currently used agent has the POTENTIAL to be nephrotoxic?
Sevo
-makes inorganic fluoride ions
99
Current FDA guidelines for Sevo use is for a minimum rate of _ L/min FGF at _ MAC hrs should not be exceeded
1L/min
2 MAC hrs
100
T/F All urologic cases that are NOT open are done with cystoscope in supine position
false
cystoscope + LITHOTOMY position
101
When performing cystoscopy, best anesthetic choice is:
short acting spinal
-analgesia
-lack of muscle movement
-real time assessment of mental status
102
When is most stimulating part of cystoscopy?
early with insertion of scope, deepen the pt most here or ensure sympathectomy
103
EWSL is used when stones are < _ - _ mm in the _ or _ ureter
10-20mm
proximal or midureter
104
Can a kidney stone in the distal ureter (lower 1/3) be removed via ESWL?
no, only ureterorenoscopy, regardless of size; AKA cystoscopy with or without stent replacement and stone removal
105
Kidney stones < _ mm are expected to pass on their own without intervention
5mm
106
Med mgmt is used for kidney stones between _ - _ mm but may need surgical intervention anyway
5-10mm
107
Kidney stones > _ mm are NOT expected to pass on their own and need urologic intervention usualyl
10mm
108
T/F ESWL is considered invasive
false
109
How do shock waves break up stones in ESWL?
-directly via mechanical stress from shock wave
-indirectly via collapse of cavitation bubbles from trailing negative pressure wave
110
Drawback of ESWL?
may need retreatments
111
Best way to check a pt for stones?
KUB CT
112
Most (~80%) kidney stones are _ -based
calcium( calcium oxalate, calcium phosphate, brushite)
-other include uric acid, struvite, cystine
113
What area can ESWL treat?
upper 2/3 of ureter
114
How can the ESWL machine injure the patient?
Waves hitting air can cause tissue injury
Patients must be still
115
Lasers may not work on stones > _ - _ cm
1.5-2cm
116
Different methods of ESWL and how they work:
Electrohydraulic (spark-gap)- underwater discharge, spherically expanding wave
Electromagnetic Lithotripter- coil and metal plate in water filled tube
Piezoelectric Lithotripter-spherical dish sends wave out from small ceramic element
117
Why is ECG lead placement important for ESWL?
-R wave is used to trigger shocks
-helps prevent arrhythmias (usually SVT or PVCs)
Surgeon may ask to give glyco or atropine to increase HR to deliver more shocks faster
118
Contraindications to ESWL?
Absolute:
Urinary obstruction below stone
Infection
Coagulopathy
Pregnant
Relative:
Aortic aneurysm
Orthopedic implant near stone
Renal insufficiency
119
ESWL complications/side effects
Hypo/hyperthermia
Cardiac dysrhythmias
Hemorrhagic blisters of skin/petechiae
Renal edema
Renal hematoma
Lung injury
Flank pain
HTN/Hypotension
N/V
Parenchymal injury
Resp difficulty
120
T/F With ESWL, moderate - severe hemorrhage can appear but is self limiting and resolves spontaneously
true
121
T/F It is common for pts to have hematuria after ESWL
true
-2/2 blood vessel rupture
122
Nephrectomy
-Anesthesia technique
-Position
-Concerns?
General anesthesia is advantageous
-rapid onset, control of pt movement
Epidural for post-op pain
A-line if inferior vena cava or renal vein is involved
Jack-knife/lateral position
-Kidney rest on non-dependent kidney
-Decrease venous return
123
If doing regional for ESWL, block needs to be between _ and _
T4-T6- short acting spinal with 50mcg sufentanil would work
124
Preop prep for ESWL:
-DC AC for 7-10days before
-need negative urine cx to prevent postop UTI/sepsis
-neg HCG for women of childbearing age
-clear liq and/or laxative for best view
125
What would make a ESWL an emergent case?
-s/s infection
-obstructed kidney
126
Intra/postop safety for ESWL:
-hydration to promote diuresis of lil bits that remain, decrease hematuria
-strict laser protocols (eye protection)
127
Nephrectomy complications
Chronic pain can ensue
PE/DVT
Pneumothorax
Brachial plexus injury
128
Are pacemakers an absolute contraindications to ESWL?
No
-Pacer may sense ESWL shock as arrhythmias unless designed to handle applied currents
-switch to fixed mode if possible
129
Contraindications to shockwave lithrotripsy
Active UTI
Uncorrected bleeding/coagulopathy
Distal obstruction
Pregnancy
130
What alters BUN?
Ingestion of protein
Anabolic/catabolic states
GFR
State of hydration
Reabsorption of urea nephron
131
What do the papillary ducts empty into?
minor calyx
132
Percutaneous nephrolithotomy
-Anesthesia
-Positioning
-Stone removal methods
General ETT
Prone or supine
-Rigid fluoroscopy to remove stone
-Laser, electrohydraulic
-Ultrasound
133
Percutaneous nephrolithotomy complications
Major:
-Infection
-Bleeding
-Pelvic/ureteral tears
-Pneumothorax/hemothorax
-Anaphylaxis
Minor:
-UTI
-Renal colic
-Fever
-Pain
134
Percutaneous nephrolithotomy can be used to remove stones _ mm or smaller and requires _ _ and postop _
25mm
GA
postop hospitalization
135
Which substances are secreted via countertransport in the kidney?
Hydrogen***
Potassium***
Urate
136
Which substances are cotransported in the kidney?
**Glucose**
Amino acids
chloride
phosphate
calcium
Mg
**H+ ions***
137
Types of TURP irrigation
Cytol
-Sorbitol + mannitol
Glycine
-Amino acid
Physiological saline
138
BPH can be managed with _ _ if the glands are small
laser therapy
139
T/F High risk pts with BPH can be managed with TURP
false,
transurethral microwave treatment and intraprostatic stents
140
Gold standard for surgically treating BPH:
TURP
141
Drugs used in med mgmt of TURP:
Alpha Blocking Agents:
-Alfuzosin (Uroxatral)
-Tamulosin (Flomax)
-Doxazosin (Cardura)
-Terazosin (Hytrin)
5-alpha-reductase inhibitors
-Finasteride (Proscar)
-Dutasteride (Avodart)
142
TURP anesthestic technique
Spinal (more dense blk than epidural)
-Preferred because you can see s/s of hypervolemia and bladder perforation
-T10 sensory level
General
-Good for patients who cannot tolerate fluid load
-Good for patients who cannot tolerate the sympathetic loss
143
TURP complications
Hyponatremia/hypervolemia
Hemorrhage
Bladder perforation
Glycine toxicity
Ammonia toxicity
Infection
Hypothermia
Skin burn
144
What affects the risk of hemorrhage during TURP?
Surgeon skill
Duration of surgery (2.5 cc/min loss)
Size of tumor
145
What is glycine toxicity? s/s?
Glycine is an inhibitory transmitter
-Many are located in the retina
-TURP blindness can occur from overabsorption of glycine
-Nausea
-Fixed/dilated pupils
-No muscle coordination
-CNS symptoms because glycine breaks down into ammonia
146
What causes the CNS symptoms from glycine?
Ammonia excess from glycine breakdown
147
Time frame you can see TURP syndrome emerge?
15 mins into case - 24hr after
148
The hallmark clinical symptoms of TURP syndrome are procedure-related due to a combo of:
-water intoxication
-fluid overload
-hyponatremia
149
When prostate gland is too large to be remove via TURP what can be done instead?
Aquablation
-robot assisted water knife
150
What is TURP syndrome?
Intravascular volume shifts, and plasma solute effects caused by absorption of irrigation fluid
-Hypo-osmolality is the main factor
151
1L of irrigant absorption over 1 hour decreases Na+ by how much?
5-8mEq/L
152
How much irrigant can be absorbed before CNS symptoms show during TURP?
2L
153
At what sodium level do TURP irrigant absorption CNS effects show?
<120mEq/L
154
What bag height of the irrigant increases risk for TURP toxicity?
60 cm above bladder
155
What increases risk of TURP syndrome? (Surgical time and prostate weight)
>1 hr resection time
80g prostate
156
What kind of breathing with TURP syndrome?
Cheyne-Stokes
157
What hematologic issues can occur from TURP syndrome?
DIC
158
Patho involved in TURP syndrome:
-Fluid Overload
-Water intoxication/ hypoosmolality
-Hyponatremia
-Glycine Toxicity
-Ammonia Toxicity
-Hemolysis
-Coagulopathy
159
Patho of TURP syndrome
-Fluid Overload s/s
-HTN
-brady
-arrhythmias
-angina
-pulm edema + hypoxemia
-CHF + HoTN
-hyperglycemia
160
Patho of TURP syndrome
-Water intoxication/ hypo-osmolality s/s
-confusion/restless
-twitch/seizures
-lethargy/coma
-dilated and sluggish pupils
-papilledema
-low voltage EEG
-hemolysis
161
Patho of TURP syndrome
-Hyponatremia s/s
-CNS changes (lethargy/coma, seizures,etc)
-reduced inotropy
-WIDE QRS
-low voltage EKG
-T wave inversion
162
Patho of TURP syndrome
-Glycine Toxicity s/s
-N/V
-HA
-transient blindness
-loss of light/accommodation reflex (blink intact tho)
-DILATED AND FIXED PUPILS
-weakness
-poor musc coordination
-myocardial depression (HoTN, less catecholamines)
-seizures (from NMDA-R stim)
-EKG changes
163
Patho of TURP syndrome
-Ammonia Toxicity s/s
-N/V
-CNS depress
164
Patho of TURP syndrome
-hemolysis s/s
-anemia
-acute renal failure
-chills/clammy skin
-chest tightness + Bspasm
-hyperK
-bradyarrhythmias/ asystole
165
Patho of TURP syndrome
-Coagulopathy s/s
-bleeding
-primary fibrinolysis
-DIC
166
TURP syndrome CV s/s
HTN/hypotension
Reflex bradycardia
Pulmonary edema
CV collapse
**EKG changes (usually at sodium < 115)
-Wide QRS
-Elevated ST
T wave inversion
-Ventricular arrhythmias (VT/ Vfib) (usually sodium < 110)**
167
Amount of fluid absorbed in TURP case depends on:
-gland size to be resected
-congestion
-duration of resection
-irrigation solution pressure
-number of sinuses open at a time
-experience of operator
168
An average of _ - _ mL of fluid can be absorbed / minute during TURP so that means in a 2hr case, pt can absorb up to _ - _ L
10-30mL/min
6-8L in 2hr
169
Why would distilled water, NS, and LR not be great for irrigating solution for TURP?
distilled water is hypoosmolar and RBCs will lyse
LR and NS are ionized and will make high current from rectoscope disperse erratically
170
Hyponatremia usually occurs from _ _, not _ _
excess water
sodium loss
171
Progressive increases of MAP, CVP, PAWP suggest _ during TURP procedure
hypervolemia
172
_ _ _ may be the first sign of hyponatremia noted.
Altered mental status
-this is why regional is better, you can see CNS changes that GA would mask
173
When glucose containing irrigation solutions are used for TURP, transient _ and _ may ensue
hyperglycemia and hypoK
174
Bladder perf
-when are s/s seen?
-depends on where it is perfed.
-surgeon will see evidence of perf 1st if pt is on GA (**inability to recover bladder fluid**)
-regional anesthesia is best to notice AMS which may be 1st s/s
175
Bladder perforation treatment
Supportive
-stop case
-treat HoTN fluids or pressors
-obtain Hct, start transfusion if needed
-perform cystourethrogram
-maybe suprapubic cath for intraperitoneal fluid or stents to help,
-lap case conversion is worst case
176
Nephrectomy complications
Chronic pain can ensue
PE/DVT
Pneumothorax
Brachial plexus injury
177
What is TURP? Indication?
-A procedure generally performed in men 60+ years, scope into urethra -> bladder -> resect prostate -> irrigated and distended to wash away prostatic tissue
-Generally done for BPH
-most common adenoma in men
178
Autonomic Dysreflexia
-Spinal level?
-What is it?
-What triggers autonomic dysreflexia?
-Generally happens above T5
-Cardiac arrest, dysrhythmias, severe hypertension below cord injury, bradycardia above the level
-Can be prevented with deep enough general, spinal or epidural
-Cutaneous or visceral stimulation
tx: deepen anesthetic, or given antihypertensive
179
5 Q to ask prior to TURP:
-What is irrigation fluid
-what is bag height over prostate
-what is size of prostate
-expected duration of case
-position for case (avoid trend)
180
Methods to detect pending TURP syndrome:
-serum Na
-monitor for fluid overload
-check mental status
-ethanol breath analysis
181
T/F Treat symptoms and altered labs aggressively when TURP syndrome occurs
false
treat labs SLOWLY, if at all
182
Early CNS red flag s/s of TURP syndrome:
-N/V
-confusion
-irritability
-HA
183
What are the 2 causes for CNS s/s in glycine toxicity?
-Biotransformation into ammonia in liver - > encephalopathy
-NMDA receptor stimulation
184
Ways to avoid skin burns in TURP:
-EKG pads
-use of bipolar enucleation of prostate, aquablation, or laser therapy
-monopolar technique has higher risk of burn
185
Blood loss in TURP case is related to 3 things:
-weight of resected tissue
-time of case
-skill of surgeon
186
Increased blood loss is seen in TURP cases when there is > _ g of resected tissue and cases > _ min
45g
90 min
187
Resected tissue in TURP cases < _ g generally won't need transfusion while _ - _ g will likely need 2 units of RBC, and > _ g up to 4 units
<30g = none
30-80g = 2 units RBC
>80g = 4 units RBC
188
Prevention of TURP syndrome:
-avoid trend (promotes absorption)
-limit resection time to <1hr**
-keep prostate capsule intact until end of resection
-put irrigation fluids <60cm above prostate**
-monitor lytes during and after case
-use regional with light sedation to detect mental status changes and DO NOT CONFUSE FOR PT BEING TOO LIGHT
189
Severe TURP syndrome treatment
1. Terminate procedure
2. Furosemide 20 mg
3. Send labs for lytes, ABGs, serum osmolality, hct; EKG, art line prolly
4. Start NS gtt, goal Na > 120 mEq/L
5. If hyponatremia is symptomatic, tx with 3% NaCl
-Tx if Na+ under 120, stop when at 120
-Never more than 100 mL/hr (avoid circulatory overload)
6. Midazolam (1mg doses) for seizures/twitching, use barb if needed
7. CXR of pulmonary edema, intubate at earliest s/s pulm edema
8. Transfuse PRBC (if DIC)
-Could also give amicar (3-5g 1st hr, then 1g/hr until bleed stopped)
190
Why not correct hypoNa+ quickly?
most feared complication = central pontine myelinolysis AKA osmotic demyelination syndrome (ODS)
-osmotic stress ->changes neuronal cells and release myelin toxin
-CNS s/s come in 1 wk and can cause sx, paralysis, or coma
191
How to manage mild TURP syndrome?
-maybe nothing needed, just monitor
-supportive tx (antiemetics, atropine, pressors, diuretics)
192
If 3-5% NaCl not available for TURP syndrome tx, ok to use _ % sodium bicarb until 3% or 5% becomes available
9% Na Bicarb
193
Best way to check fluid status on TURP pt?
TEE
194
Pain impulses from the bladder neck and prostate are propagated by _ _ fibers from the _ and _ sacral roots along with pelvic _ nerves.
afferent PNS
2nd and 3rd
splanchnic
195
The sympathetic nerves via the _ plexus, which is derived from _ - _ nerve roots transmit sensation from the bladder, so a _ sensory block is needed for good anesthesia
hypogastric
T11-L2
T10
196
Why would GA be good for a pt having a TURP done?
if they can't handle fluid load to compensate loss of sympathetic tone from regional or if they need pulmonary support
197
What can be given to a pt pre-TURP if they are having regional anesthesia to prevent HoTN
fluid loading CAUTIOUSLY
198
Urogenital system is a _ system and if insufflated with CO2 will communicate with thorax and subq tissue freely
retroperitoneal
199
Intraperitoneal pressure > _ mmHg results in hemodynamic changes like reduced CO and increased SVR
10mmHg
200
_ (increased/decreased) renal perfusion activates RAAS system
decreased
-causes vasoconstriction
201
Ideal IV fluid to use for TURP case:
NS
202
Pros of lap cases:
-more precise procedure from magnification of site
-less postop pain
-better cosmetic results
-quicker return to normal activity
-decrease LOS
-cost of care reducion
-less intraop bleeding
-fewer postop pulm and wound infections
-less metabolic changes
-better postop resp function
203
Cons of lap cases:
-possible extravasation of insufflated CO2 to retroperitoneal space/ thorax
-possible postop airway compromise from emphysema
-acidosis more frequent from CO2 absorption
-intraop oliguria more frequent from peritoneal pressure increases
-possibly longer case than if open
204
What can be done to improve splanchnic and renal perfusion during lap cases?
SCD on BL LE **15 min** after pneumoperitoneum achieved
-lowers SVR, improves CO
205
Radical cystectomy
-Approach
-Anesthetic
-Position
1. Remove part or all of bladder (usually for bladder CA, urostomy)
2.
-Monitor u/o closely
-Procedure 4-6 hours
-EBL 1.5L
206
Radical prostatectomy
-Approach
-Anesthetic
-Position
1. Retropubic/perineal
2. General/regional/combo
-Massive blood loss
3. Steep trendelenburg with lithotomy lap or robot
207
2 main type of major urologic surgeries:
Upper Tract Surgery
-simple or radical nephrectomy
-radical nephroureterectomy
-nephron-sparing surgery
Pelvic Surgery
-radical cystectomy
-urinary diversion
-radical prostatectomy
208
Benefits of robot cases:
-enhanced and magnified 3D view
-less scattered ambient light
-less surgeon fatigue
-less hand tremor
-better dexterity
-bloodless field
-less blood loss
-shorter LOS
209
Major complications of cases done in trend position:
-neuropathy
-CVP elevation
-IOP + ICP elevation
-increased pulm venous pressure
-less pulm compliance
-less FRC
-swelling of face/airway
210
Prolonged lithotomy position problems:
-lower extremity nerve issue (usually femoral n
-compartment syndrome and PI on LE
211
Prolonged trend position problems (nerve)
ocular injury
-corneal abrasions, ischemic optic neuropathy from high IOP
212
T/F Most organ donation comes from live donors
false
brain dead
213
Why would someone need a nephrectomy?
tumor or polycystic problems
214
Open nephrectomy is performed in which position? What are some problems with this?
jack knife lateral position with rased kidney rest or bump to displace it superficially
-vena cava is compressed! decreased venous return and BP
-decreased compliance, increased PIP, atelectasis possible in dependent lung
-this case is very stimulating so need really good anesthesia on board (maybe lowers BP more)
215
If pt has scleral edema, what else is probably edematous?
airway/ vocal cords
wait longer to extubate or don't
216
Urologic robot cases position:
steep trend (~27degrees), arms wrapped at sides
217
Drugs to reduce gastric acid and increase emptying for robot cases :
metoclopramide, famotidine
218
What can be given in recovery for bladder spasm?
Buscopan
-can increase HR tho
219
Urologic robot cases and fluid:
-limit therapry while lower renal tract is disrupted (<800mL)
-give ~1200mL once reconnected and confirm w surgeon
(total 2L)
-blood loss usually <300mL
220
Emergence tips for urologic robot cases:
-after robot disengaged, level bed and do lung recruitment maneuvers
-consider spinal (want ~3hr coverage)
-sit pt up and slow wake up ~10-15 min to reduce cerebral edema and agitation-check -for cuff leak before extubating
