Effects Of Anesthesia And Surgery On The Kidney

Front 1

Both regional and general anesthesia cause reversible declines in? 4

Back 1

RPF, GFR, urine flow rate, and urine sodium excretion; alterations tend to be less with regional anesthesia

Front 2

Most anesthesia-related changes in renal function are?

Back 2

indirectly mediated

Front 3

Anesthetic agents may cause?

Back 3

cardiac depression and peripheral vasodilation, and reduce MAP below the lower limit of renal autoregulation

Front 4

Anesthesia can activate?

Back 4

activiation of the SNS(stress response) causing renal vasoconstriction

Front 5

What can anesthesia stimulate?

Back 5

hormone secretion (ADH, aldosterone) can facilitate sodium and water retention

Front 6

What are direct effects of anesthetic agents on renal function ? 3

Back 6

1. Halothane and isoflurane may reduce vascular resistance
2. Methoxyflurane - nephrotoxicity secondary to fluoride ion release
3. Possible sevoflurane nephrotoxicity

Front 7

Eger et al. reported what with sevo?

Back 7

transient renal injury in normal volunteers administered 1.25 MAC sevo for 8 hours at a flow rate of 2 L/min
-but several other investigators have not found evidence of adverse effects of sevo on renal function

Front 8

If nephrotoxicity occurs, it is most likely due to?

Back 8

Compound A produced by sevoflurane degradation when the agent is passed at slow rates through Baralyme CO2 absorbent

Front 9

NSAIDS and ACE inhibitors may?

Back 9

exaggerate the effects of anesthesia and surgery on renal function

Front 10

Preoperative considerations (KDOQI 2-4) assess?

Back 10

level of renal function, Ccr

Front 11

In patients in renal failure stages 2-4 what should emphasis be on?

Back 11

prevention of postoperative ARF (mortality rate of 50-60%) particularly in patients undergoing surgical procedures that increase the risk of postop ARF

Front 12

What things could you do to avoid ARF in patients in stages 2-4 renal disease already? 2

Back 12

1. Preop administration of a balanced salt solution may correct hypovolemia
2. Mannitol, low-dose dopamine, fenoldopam, or loop diuretic may be administered to maintain urine flow

Front 13

What preoperative medications are safe to administer to a renal failure stage 2-4 patient?

Back 13

1. Benzodiazepines
2. Anticholinergic agents (atropine)
3. Histamine-2 receptor blocker

Front 14

With the administration of benzodiazepines what things should you consider?

Back 14

that they undergo hepatic metabolism before excretion in the urine and thus safe to use; however, hypoalbuminemia may increase sensitivity due to increased free fraction of drug

Front 15

What should you consider when administering anticholinergic agents in patients with renal failure in stages 2-4?

Back 15

possible accumulation with repeated doses

Front 16

What are histamine-2 receptor blockers used for?

Back 16

to increase gastric pH

Front 17

What can an increased bleeding time be corrected by?

Back 17

administration of cryoprecipitate or DDAVP

Front 18

What is included in standard monitoring during the intraoperative time?

Back 18

urine flow rate - output greater than 0.5 mL/kg/hr is desired

Front 19

During induction of anesthesia what do you want to make sure is adequate?

Back 19

the intravascular volume is adequate, otherwise hypotension may occur on induction

Front 20

What drug may have an increased sensitivity due to increased free fraction of drug?

Back 20

thiopental

Front 21

Are the pharmacokinetics of ketamine, propofol, and etomidate significantly altered?

Back 21

no

Front 22

Is succinylcholine safe to use?

Back 22

yes, provided that serum potassium concentration is less than 5meq/L

Front 23

What neuromuscular agents are the drugs of choice?

Back 23

atracurium and cisatracurium, they are not dependent on renal clearance

Front 24

What two neuromuscular agents may be modestly prolonged?

Back 24

vecuronium and rocuronium

Front 25

What gases are considered acceptable to use during the maintenance of anesthesia?

Back 25

nitrous oxide together with either isoflurane or desflurane, some practitioners avoid sevoflurane because of concerns regarding fluroide ion release or compound A production

Front 26

Are opioids safe to administer?

Back 26

most opioids are suitable, possible avoid morphine and meperidine as active metabolites may accumulate

Front 27

Fluid therapy during maintenance of anesthesia

Back 27

administer a balanced salt solution to maintain normal or slightly expanded intravascular volume

Front 28

T or F. Symptoms of fluid overload (pulmonary congestion) are easier to treat than are symptoms of ARF.

Back 28

True

Front 29

Which antiemetics can be used?

Back 29

metoclopramide- does not depend on renal function for clearance, phenothiazenes, droperidol, and 5-HT3 receptor blockers can be used as well

Front 30

Preop considerations for patients in stage 5 renal failure (3)

Back 30

Thorough patient eval; uremia is likely
1. Evaluate intravascular volume status; hyper- or hypovolemia may be present
2. RBC transfusion may be given for severely anemic patient
3. Evaluate preoperative drug therapy

Front 31

Premedication considerations for patients in stage 5 renal failure (3)

Back 31

1. increased sensitivity to benzodiazepines and dexmedetomidine
2. Continue preop medications, especially hypertensive agents
3. Histamine-2 receptor blocker can be used to increase gastric pH

Front 32

Should you place the BP cuff on the arm with the fistula?

Back 32

no, invasive monitoring may be necessary

Front 33

Induction of anesthesia with patients who have nausea, vomiting, or GI bleeding should undergo?

Back 33

RSI

Front 34

What induction drugs can be used with patients in stage 5 renal failure?

Back 34

thiopental (reduced dose), propofol, etomidate, or ketamine can be used for induction

Front 35

What muscle relaxants should be used with patients in stage 5 renal failure?

Back 35

atracurium and cisatracurium

Front 36

What volatile agents are preferred in patients in stage 5 renal failure?

Back 36

isoflurane and desflurane- least effect on CO

Front 37

In patients with very low Hb what should you avoid?

Back 37

nitrous oxide- allows for administration of 100% oxygen

Front 38

Which opioid should you use and which one should you avoid in stage 5 renal failure patients?

Back 38

fentanyl is excellent opioid, avoid meperidine and morphine (accumulation)

Front 39

What other way could you maintain anesthesia intraoperatively with these patients?

Back 39

TIVA with remifentanil, propofol, and cisatracurium

Front 40

Fluid therapy for stage 5 renal patients undergoing superficial procedures with little fluid loss?

Back 40

D5W may be used to replace insensible water loss

Front 41

Procedures that cause large fluid loss or shifts require administration of?

Back 41

a balanced salt solution and/or colloid solution

Front 42

In patients with hyperkalemia what solutions should you avoid?

Back 42

glucose-free solutions and LR

Front 43

In aortic cross-clamping what is the most important determinant of RBF changes and probablitly of postop ARF?

Back 43

level of clamping

Front 44

What is the incidence of ARF after infrarenal clamping?

Back 44

5%

Front 45

What is the incidence of ARF after suprarenal clamping?

Back 45

13%

Front 46

Postop mortality is ______ times higher in patients who develop ARF than in those who do not

Back 46

4-5

Front 47

Suprarenal clamping reduces? and increases?

Back 47

RBF by 80% and increases fractional distribution of RBF to the cortex

Front 48

Infrarenal clamping reduces RBF by?

Back 48

45%

Front 49

How long does RBF remain depressed following release of clamp and return of systemic hemodynamics to normal?

Back 49

30 min or more

Front 50

What are some methods of renal protection during cross-clamping of the aorta?

Back 50

1. Dopamine (2-3 micrograms/min)
2. Fenoldopam (DA-1 receptor agonist)
3. Furosemide
4. Mannitol

Front 51

Mannitol produces?

Back 51

diuresis and acts as a free radical scavenger
-does not necessarily improve outcomes

Front 52

What has been found to be the most important in preventing postop ARF?

Back 52

good hydration during clamping and after clamp release

Front 53

Is intraoperative urinary output a predictor of postop renal fx?

Back 53

no

Front 54

What is the most reliable predictor of postoperative renal dysfunction after aortic cross-clamping?

Back 54

is preoperative renal dysfunction ie, elevated Scr or BUN or decreased Ccr

Front 55

What is the effect of endovascular aortic surgery on renal function?

Back 55

prevalence of renal complications similiar to that with open surgery

Front 56

Why is the endovascular approach not any better than the open approach?

Back 56

large amounts of radiocontrast dye may be used- can aggravate preexisting renal dysfunction

Front 57

What may be dislodged into the kidneys and contribute to ischemia?

Back 57

atherosclerotic debris

Front 58

What is warranted to lessen the risk of postop renal dysfunction?

Back 58

good hydration