Renal labs extra from oral

Question 2

PT, PTT, bleeding time in CRF, reason and Tx

Answer 2

• increased bleeding despite normal PT, PTT, and BT- cause is defective vWF Give DDAVP 0.3-0.4mg/Kg over 30 minutes or cryo, also have blood warmer ready to go

Question 3

Hyperkalemia common, what EKG changes does it produce

Answer 3

Peaked T, long PR, long QRS, ST depression HB and V-fib can result

Question 4

HyperMg leads to

Answer 4

CNS depression and coma

Question 5

high or low pH in CRF

Answer 5

low, can’t excrete H+ ions

Question 6

CXR for

Answer 6

HTN CV disease, pericardial effusion, uremic pneumonitis

Question 7

Dig tox EKG

Answer 7

Short QT, ST depression

Question 8

Hypocalcemia EKG

Answer 8

Long QT

Question 9

RF and drugs

Answer 9

Anemia, low serum protein, e-lyte changes, fluid retention, changed cell membrane dynamics all affect drugs Drugs excreted by the kidney unchanged are CONTRAINDICATED, like gallamine, phenobarbital

Question 10

Common anesthetic drugs to use with caution in RF

Answer 10

Thiopental- high PB Midazolam- 60-80% renal clearance, high PB Dexmedetomidine- high PB

Question 11

Opioid of choice in RF

Answer 11

Fentanyl Remi also ok

Question 12

Bad opioids in RF

Answer 12

Meperidine, morphine, hydromorphone

Question 13

Muscle relaxants to avoid in RF

Answer 13

d-tubo, metocurine, gallamine, pancur, pipecur, doxacur Vec, roc ok (30% renal), but may see longer effect

Question 14

Extra caution with succs because

Answer 14

K is released! Only use if K is normal, but probably want to avoid it

Question 15

What is the most common cause of high BUN

Answer 15

CHF secondary to the reabsorption of BUN Low CO causes lows kidney perfusion. Kidneys try to correct perceived fluid deficit by reabsorbing urea.

Question 16

Why is anemia common in renal failure?

Answer 16

1) Decreased EPO production 2) Build-up of toxins decreases the lifespan of RBCs

Question 17

Chronic renal patients will usually have an increased or decreased CO?

Answer 17

Increased to compensate for the anemia

Question 18

Hemoglobin levels as low as __-__ are common for renal patients, so don’t freak out

Answer 18

5-8

Question 19

Renal patients usually have fucked up coags. Which coags are fucked up and why?

Answer 19

PT, PTT, and bleeding time. These are fucked up because they have shitty vWF. Treat this by replacing vWF.

Question 20

How can you treat the fucked up coags seen in renal dysfunction?

Answer 20

Replace the vWF! 1) Desmopressin .3-.4mg/kg over 30 min) - Desmopressin will increase the release of vWF from endothelial cells 2) Cryoprecipitate (remember that this contains factor VIII, XIII, fibrinogen, and whaddup –> vWF!)

Question 21

The hyperkalemia seen in RF can result in these EKG changes

Answer 21

Peaked T waves, ST depression, prolonged PR interval and QRS complex, heart block, and V-fib

Question 22

Hypermagnesemia resulting from RF can cause

Answer 22

Coma and CNS depression Prolongs the duration of NMBs

Question 23

Why do we use a microdripper to give fluids in renal patients?

Answer 23

To make sure we don’t fluid overload them

Question 24

Why does RF cause HTN?

Answer 24

1) Renin release by the diseases kidney 2) High intravascular fluid volume d/t inappropriate handling of sodium and water

Question 25

RF can lead to ____ pericarditis and cause

Answer 25

uremic pericarditis tamponade

Question 26

Hypocalcemia causes this on EKG

Answer 26

Prolonged QT

Question 27

Digitalis toxicity produces this on EKG

Answer 27

Shortened QT and depressed ST

Question 28

These meds are excreted via the kidneys unchanged and are contraindicated in RF

Answer 28

Gallamine (100% renal elimination) and phenobarbital

Question 29

Is UO predictive of post-op renal insufficiency?

Answer 29

No

Question 30

What can happen if you give too much fluid to your anuric renal patients?

Answer 30

CHF and pulmonary edema

Question 31

UO during surgery should be maintained at this rate

Answer 31

0.5cc/kg/min If it falls, we can give 5mg of lasix

Question 32

A 50% increase in plasma creatinine means

Answer 32

A 50% reduction in GFR

Question 33

This is the source of creatinine

Answer 33

Skeletal muscle

Question 34

We are concerned about K+ when it is over

Answer 34

5

Question 35

When is vasopressin released?

Answer 35

Released by the posterior pituitary in response to high serum osmolarity and acts on the kidneys

Question 36

This is the dose for low-dose dopamine

Answer 36

1-2mcg/kg/min

Question 37

Effect of neuraxial anesthesia in renal dysfunction

Answer 37

• T4-T10 sympathectomy will decrease the release of catecholamines, renin, and vasopressin (ADH) o This is because we’re causing vasodilation and blocking the sympathetic response! o Make sure to pre-hydrate before placement! • Key to maintenance of renal blood flow and GFR is you have to maintain renal perfusion pressure – fluid boluses etc. o Remember that proper RBF is dependent on MAP

Question 38

Effect of PPV on renal function, and how we can over come this

Answer 38

• The higher the PIP and PEEP the greater the decrease in RBF, GFR, and urine flow rate o Probably because PPV will decrease venous return and CO We can overcome this by hydrating.

Question 39

Creatinine Clearance

Answer 39

Normal is 125mL/min •

Question 40

What may a CXR show in the patient with renal failure?

Answer 40

• LVH o Determine presence of hypertensive cardiovascular disease • Pericardial effusion (from uremic pericarditis) • Uremic pneumonitis- RF patients have chronic pulmonary edema → fluid overload, shitty heart function, and leaky capillaries

Question 41

Avoid these NMBs in renal failure

Answer 41

d-tubocurarine, metocurine, gallamine

Question 42

What is the most common cause of death in renal failure?

Answer 42

Infection Make sure to use aseptic technique!!

Question 43

IAs for RF

Answer 43

 Halothane  Avoid- High K+ & acidosis-\> myocardial irritability  Enflurane  Avoid- fluoride concern  Sevoflurane  Controversial: some practitioners remain concerned regarding Compound A and fluoride  Isoflurane/Desflurane  Volatile agents ideal-no dependence on kidney for elimination  Accelerated induction and emergence seen with severe anemia  Anemia results in decreased solubility of the IA

Question 44

Ventilation goals in RF

Answer 44

 Hypoventilation exacerbates acidosis  Hypercapnia predisposes to cardiac arrhythmias from acidosis  Alkalosis shifts oxy-hgb curve to left- less O2 available to tissues  Overall, we want to maintain normal acid/base balance  Remember too that they are anemic and we want to do this to keep the O2 dissociation curve to the right!! Remember that high PIP and PEEP will decrease RBF

Question 45

This is the pressor of choice for renal pts

Answer 45

Ephedrine

Question 46

What's the deal with H2 blockers and renal failure?

Answer 46

H2 blockers are highly dependent on renal excretion