Nurs614 - Exam 3 Anesthesia For Renal Disease

Front 1

What are the most useful laboratory tests to evaluate renal disease?

Back 1

Those tests related to GFR

Front 2

What is the best way to get a true GRF evaluation?

Back 2

A 24hrs collection

Front 3

Primary source of urea is in the ------?

Back 3

Urea production occurs in the liver

Front 4

What is ammonia the product of?

Back 4

Ammonia is produced from deamination of amino acids (protein catabolism)

Front 5

How does the body prevent accumulation of toxic ammonia levels?

Back 5

By hepatic conversion of ammonia to urea.

Front 6

HOW DOES END STAGE LIVER DISEASE AFFECT THE KIDNEYS?

Back 6

END STAGE LIVER DISEASE LEADS TO END STAGE RENAL DISEASE

Front 7

What is the correlation between BUN and protein catabolism?

Back 7

There is a direct correlation.
BUN measures the amt of nitrogen in blood that comes from the waste product urea. Urea comes from protein catabolism.

Front 8

How is BUN and GFR related?

Back 8

They are inversely related

Front 9

When is BUN not a reliable indicator of GFR?

Back 9

When protein catabolism is abnormal and not constant

Front 10

When is BUN lower than normal?

Back 10

Starvation or liver disease

Front 11

How does septicemia affect protein catabolism?

Back 11

Septic pts do not have constant rate of protein catabolism

Front 12

What is normal BUN

Back 12

10-20mg/dL

Front 13

What is creatinine?

Back 13

The product of muscle metabolism

Front 14

How is creatinine related to muscle catabolism and to GFR?

Back 14

Positively r/t muscle catabolism, inversely r/t to GFR

Front 15

True/false?
Creatinine is generally a reliable indicator of GFR

Back 15

True

Front 16

What is normal creatinine levels?

Back 16

Males 0.8-1.3mg/dL
Females 0.6-1.0mg/dL

Front 17

How does aging affect GFR

Back 17

GFR declines with increasing age

Front 18

How does aging affect creatine levels?

Back 18

Serum creatinine remains relatively normal with increasing age

Front 19

Normal BUN:creatinine ratio is ___?

Back 19

~ 10:1

Front 20

How does low renal tubular flow rates affect urea reabsorption & creatinine levels?

Back 20

It enhances urea reabsorption but does not affect creatinine handling (as a result, the ratio increases > 10:1).

Front 21

A decrease in tubular flow can be caused by ____ ?

Back 21

Decreased renal perfusion or obstruction

Front 22

BUN:Creatinine ratios greater than 15:1 are seen in ______?

Back 22

Volume depletion, disorders associated with decreased tubular flow, obstructive uropathies (eg renal stones), and increases in protein catabolism (clogs up tube)

Front 23

What is the most accurate method available for clinically assessing overall renal function (GFR)?

Back 23

CREATININE CLEARANCE

Front 24

Measurements of creatinine clearance are usually performed over _____ ?

Back 24

24 hours

Front 25

What is normal creatinine clearance?

Back 25

110-150mL/min

Front 26

What is the creatinine clearance in mild renal impairment?

Back 26

40-60mL/min

Front 27

What is the creatinine clearance in moderate renal dysfunction?

Back 27

25-40mL/min

Front 28

A creatinine clearance of <25mL/min is indicative of?

Back 28

Overt renal failure

Front 29

What is the purpose of a URINALYSIS?

Back 29

It is useful in identifying some disorders of renal tubular dysfunction

Front 30

What does urine osmolality measure?

Back 30

Renal concentrating ability

Front 31

What causes glycosuria?

Back 31

It is the result of a low tubular threshold for glucose or hyperglycemia

Front 32

How are the pharmokinetics of propofol affected when kidney function is altered?

Back 32

The pharmokinetics are not
significantly affected

Front 33

How are the pharmokinetics of etomidate affected when kidney function is altered?

Back 33

The pharmokinetics are not
significantly affected

Front 34

How are the pharmokinetics of barbituates affected when kidney function is altered?

Back 34

Pts with renal disease often exhibit increased sensitivity to barbs during induction even though pharmokinetic profiles appear to be unchanged.

Front 35

In the pt with RI, what is a possible explanation for increased circulating barbs?

Back 35

Decrease protein binding

Front 36

How does acidosis affect barbs?

Back 36

It favors a more rapid entry in the brain by decreasing the nonionized fraction of the drug

Front 37

How are the pharmokinetics of benzos affected when kidney function is altered?

Back 37

Benzos undergo hepatic metabolism & conjugate prior to elimination in the urine.
B/c most are highly protein bound, increased sensitivity may be seen in pts with hypoalbuminemia

Front 38

How are the pharmokinetics of morphine & demerol affected when kidney function is altered?

Back 38

Morphine with active metabolite (morphine-6 gluconaride) & demerol have been known to have prolonged resp depression in pts with renal failure

Front 39

How are the pharmokinetics of opioids affected when kidney function is altered?

Back 39

With the exception of morphine & demerol, significant accumulation does not occur

Front 40

How are opioids eliminated?

Back 40

Most commonly used opioids are inactivated by the liver & some of their metabolites excreted in the urine

Front 41

What are the effects of IAs on renal function?

Back 41

IAs are nearly ideal for patients with renal dysfunction.
Enflurane and Sevoflurane have potential for fluoride accumulation.
Isoflurane can react with baralyme to form compound A.

Front 42

With the pt with altered renal function, what lab value must be obtained before the use of succinycholine?

Back 42

K level.
Succinycholine can increase K level by 1meQ.

Front 43

What are the MRs of choice for pts with renal failure?

Back 43

Atracurium and Cisatracurium –they are minimally dependent on the kidneys for elimination.

Front 44

How is vecuronium eliminated?

Back 44

Primarily hepatic but up to 20% of the drug is eliminated in the urine.

Front 45

How does renal insufficiency affect vecuronium?

Back 45

With large doses (>0.1mg/kg) effects only modestly prolonged.

Front 46

How is Rocuronium metabolized?

Back 46

Primarily by the liver but elimination is prolonged with RI.

Front 47

How is Pancuronium metabolized & eliminated?

Back 47

It is metabolized by the liver into less active intermediates but its elimination half life is 60-80% & is dependent on renal excretion.

Front 48

How is renal failure classified?

Back 48

According to predominant cause or on the basis of urine flow rates.
Causes are of prerenal, renal, or postrenal origins.

Front 49

How is curare eliminated?

Back 49

By renal and biliary excretion. 40-60% of a dose of curare is normally eliminated in the urine. Repeated does --> increasingly prolonged effects in pts with significant RI.

Front 50

Atropine & renal impairment?

Back 50

Can generally be safely given although some accumulation may occur since about 50% of Atropine and its active metabolite are normally excreted in the urine. Potential for accumulation exists following repeated doses.

Front 51

Glycopyrrulate & renal impairment?

Back 51

Can generally be safely given although some accumulation may occur since about 50% of Glycopyrrulate and its active metabolite are normally excreted in the urine. Potential for accumulation exists following repeated doses.

Front 52

Scopolamine & renal impairment?

Back 52

It is less dependent on renal excretion but its CNS effects can be enhanced by azotemia.

Front 53

What is oliguric acute renal failure

Back 53

UO < than 500 milliliters per day (< 16 oz/day)

Front 54

What is nonoliguric renal failure?

Back 54

UO > 500 ml/day (>16 oz/day)

Front 55

What are the 3 types of renal failure classification according to urine flow rates?

Back 55

Nonoliguric acute renal failure;
Oliguric acute renal failure;
Anuric renal failure.

Front 56

True/false?
Prerenal and postrenal acute renal failure are reversible in initial stages

Back 56

True

Front 57

What are the causes of renal failure?

Back 57

Renal ischemia
Nephrotoxins
Intrinsic renal disease

Front 58

List 5 preoperative anesthetic management
strategies for ARF

Back 58

Placement of urinary catheter;
Fluid challenge if urinary output decreases;
Renal dose dopamine as applicable;
Diuretic therapy associated with aggressive monitoring and intravascular volume expansion;
Prophylactic administration of mannitol, dopamine, or lasix.

Front 59

What are the phases of the ARF?

Back 59

Onset (initiation phase)
Oliguric phase
Diuretic phase
Recovery phase

Front 60

After renal failure has been established, what are anesthetic management strategies?

Back 60

Maintenance of fluid and electrolyte balance;
Early use of hemodialysis during oliguric and diuretic phases

Front 61

Progressive renal failure is divided into three stages, what are they?

Back 61

Decreased renal reserve (pt will be coming in for AV shunts);
Renal insufficiency;
End-stage renal failure or uremia.

Front 62

What are the major types of dialysis?

Back 62

Hemodialysis
Peritoneal dialysis (can cause peritonitis easily)

Front 63

What is azotemia

Back 63

It is the retention of nitrogenous waste products resulting in deterioration of renal function.

Front 64

Azotemia is classified according to cause. There are 3 types. What are they?

Back 64

Prerenal, renal and post-renal

Front 65

What causes prerenal azotemia?

Back 65

Acute decrease in renal perfusion

Front 66

What causes renal azotemia?

Back 66

It is d/t intrinsic renal disease, renal ischemia, or nephrotoxins.

Front 67

What causes postrenal azotemia?

Back 67

Urinary tract obstruction or disruption.

Front 68

What are the physiologic effects of dialytic therapy on the CNS?

Back 68

It causes disequilibrium syndrome

Front 69

What are the physiologic effects of dialytic therapy on the CV System?

Back 69

Hypotension;
Anemia (RBCs break up b/c of the agitation from the HD machine which can --> hypoxemia).

Front 70

What is the physiologic effect of dialytic therapy on the resp system?

Back 70

Hypoxemia

Front 71

In the preop management of chronic renal failure (CRF), what are the lab values that should be obtained?

Back 71

Creatinine clearance
BUN
Serum creatinine
Urinalysis
CBC
Coags

Front 72

With the CRF pt who gets HD, sometimes the serum coag levels are normal but the pt may still have a coagulopathic problem. Explain.

Back 72

Plts may be damaged during HD and the value may look normal but all the plts are not functioning well.
We still need baseline coags to evaluate what's going on with pt.

Front 73

What are the CV alterations in advance renal disease?

Back 73

HTN
CHF

Front 74

What are the hematological changes in advance renal disease?

Back 74

Anemia
Prolonged bleeding time (from plts in suboptimum condition)

Front 75

What are the GI effects in advance renal disease?

Back 75

Increased risk of GIB

Front 76

What are the neurologic effects of advance renal disease?

Back 76

Symptoms parallel degree of azotemia
Seizures may be associated with hypertensive encephalopathy

Front 77

What are the endocrine abnormalities associated with advance renal disease?

Back 77

Hyperparathyroidism
Adrenal insufficiency

Front 78

What are the repiratory effects associated with advance renal disease?

Back 78

Pneumonitis
Pulmonary congestion and edema

Front 79

What are the electrolyte abnormalities associated with advance renal disease?

Back 79

Altered sodium, calcium, potassium & magnesium levels. It causes acidosis

Front 80

Replacement of CaCl needs to be slow pushed. Why?

Back 80

Fast push can cause sustained bradycardia & hypotension

Front 81

What is the periop management of the CRF pt with hyperkalemia?

Back 81

If possible dialyzed.
If not possible, infuse glucose & give insulin and Bicarb

Front 82

What % of most anesthetic practices does urologic procedures account for?

Back 82

10-20%

Front 83

What is the age group of the pts who most often have urologic procedures?

Back 83

Patients may be of any age, yet most are elderly and have many coexisting illnesses, especially renal dysfunction

Front 84

What is the pt's positioning for cystoscopy?

Back 84

Lithotomy

Front 85

What surgical approach is used for cystoscopy?

Back 85

The scope is inserted thru the urethra up to the bladder to visualize the ureters

Front 86

How long does a cystoscopy alone take?

Back 86

10-15 mins long.
(just use MAC & lidocaine jelly, sml propofol gtt)

Front 87

For cystoscopy procedure, if procedure is longer than 15mins and GA is being used, can the LMA be used?

Back 87

Yes. If pre-operative evaluation permits.
If >2hrs place an ETT and use PP ventilation.

Front 88

If spinal anesthesia is being used for a cystoscopic procedure, when would we not use lidocaine?

Back 88

If the procedure will be longer than 3hrs

Front 89

What is the most common major complications associated with TURP?

Back 89

TURP Syndrome - systemic absorption of bladder irrigant

Front 90

During bladder irriagtion, what is the major complication of disproportionate flow in and out of bladder?

Back 90

Rupture of Bladder

Front 91

What occurs if TURP is complicated by DIC?

Back 91

Thromboplastins from prostate can enter the blood stream.

Front 92

What is a possible major complications of TURP (used to tx cancerous tumors)?

Back 92

The tumor may release fibrinolytic enzymes into the blood --> coagulopathy

Front 93

If TURP syndrome occurs, does it happen intraop or postop?

Back 93

TURP Syndrome
can occur intraoperatively and postoperatively.

Front 94

What are symptoms of TURP syndrome in the awake pt?

Back 94

H/A, restlessness, confusion & seizures (from hyponatremia and water intoxication), cyanosis, dyspnea, arrythmias, and hypotension.

Front 95

What are symptoms of TURP syndrome in the sleeping pt?

Back 95

Hypo-osmolality, fluid overload (CHF, Pulmonary Edema), Hemolysis

Front 96

Treatment of TURP Syndrome includes?

Back 96

Early recognition and treatment of symptoms;
Supportive care to avoid hypoxemia and hypoperfusion;
Water restriction (for a few days) and loop diuretic to remove excess fluid;
Hypertonic saline to tx symptomatic hyponatremia which could lead to seizures or coma.

Front 97

How fast should 3% saline be given?

Back 97

To avoid circulatory overload, 3% NaCl should not be given faster than 100 ml/hr

Front 98

What is EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL)?

Back 98

Shock waves are used to break apart a kidney stone to allow for passage through the urethra

Front 99

How does older and newer ESWL machines differ?

Back 99

Older machines use a submersion tank with water to conduct shockwaves into the body while newer machines use gel pads to conduct shockwaves into the body.

Front 100

How does ESWL affect pts with heart disease & implantable devices (like pacemakers or AICDs)

Back 100

ESWL can cause arrythmias.

Front 101

For pts with pacemakers, how is the ESWL device timed in relationship to the pacemaker?

Back 101

It is timed with the HR so machine does not throw pt into arrhythmias.

Front 102

Regarding ESWL, what should be done for pts with chronic AFib prior to the procedures?

Back 102

The pacer/AICD may have to be turned off since the machine only fires with the EKG phases of the pacemaker, control of the HR to allow for better results is essential. For pts with chronic afib, etc, this may be diificult. Make sure the machine is turned back on post-op.

Front 103

When the immersion method of ESWL is used, how does it affect blood pressure?

Back 103

Immersion in a hot water bath can initially lead to vasodilation and hypotension.

Front 104

When the immersion method of ESWL is used, how does it affect cardiac output?

Back 104

The compression of the peripheral vasculature by the pressure of the water can lead to increase in venous return which will cause increase in SVR, decrease in CO.
Increase in blood in the central compartment will lead to exacerbation of CHF

Front 105

When the immersion method of ESWL is used, how does it affect FRC?

Back 105

ESWL --> increased intra-thoracic blood volume which reduces FRC by 30-60% and predisposes patients to hypoxemia

Front 106

When regional anesthesia is chosen for ESWL, which is the better choice - spinal or epidural?

Back 106

Epidural is preferred – it allows for re-dosing during a longer procedure

Front 107

True/false?
ESWL can damage the internal components of the pacemaker & AICD

Back 107

True

Front 108

Which wave of the ECG is the ESWL synchronized to?

Back 108

The R-wave

Front 109

How many seconds after the R-wave is the ESWL timed?

Back 109

20ms (to correspond with the ventricular refractory period).

Front 110

True/false?
Studies show that asynchronous delivery of ESWL is dangerous in pts w/o heart disease

Back 110

False

Front 111

Continuous epidural anesthesia is commonly used for ESWL using emmersion. What level epidural placement ensures adequate anesthesia?

Back 111

T6. Renal iinervation is derived from T10 to L2

Front 112

If a large amt of air gets into the ESWL epidural, what effect will it have?

Back 112

It dissipate the shock waves and theoretically may promote injury to neural tissue

Front 113

Large amounts of hydration fluid are required during ESWL, why?

Back 113

To ensure adequate urinary production and flow to remove debris from kidney stone
(Lasix can be given in conjunction with fluid to increase urinary output)

Front 114

As part of fluid management in normavolemic pts during ESWL, a unit or two of blood can be taken out of the pt & kept on a rotator. What do we replace this with and what do we do with the blood after completion of ESWL?

Back 114

We replace it with crystalloids & after the procedure,give the blood back.

Front 115

Radical prostatectomy is___?

Back 115

Removal of the prostate, usually due to cancer

Front 116

As part of intraop consideration for radical prostatectomy, what is the expected blood loss?

Back 116

It is usually a large blood loss (300-500 ml) due to the vascular nature of the prostate and the approach to remove the prostate.

Front 117

During radical prostatectomy, the neck of the bladder is removed. What effects does this have I/O mngmnt?

Back 117

This leads to loss of urine output from the catheter.

Front 118

How is indigo carmine or methylene blue used in radical prostatectomy?

Back 118

Indigo carmine or methylene blue may be used to help identify the ureters during the resection.

Front 119

An epidural can be used in a radical prostatectomy, what consideration must be made regarding sedation?

Back 119

It will require large amounts of sedation.

Front 120

How does GA compare to regional anesthesia for radical prostatectomy ?

Back 120

GA allows for better control of the airway in a trendelengberg position.
Spinals are not to be used b/c the anesthesia duration is not long enough.

Front 121

During radical cystectomy, why is accurate measurement of UO not possible?

Back 121

The bladder will be removed. (and construction of urinary pouch is necessary).

Front 122

During radical cystectomy, how is urinary diversion created?

Back 122

Urinary diversion involves placement of ureters into a segment of the bowel which is connected to a stoma formed in the abdomen for placement of a catheter post operatively

Front 123

What is the preferred mode of anesthesia during radical cystectomy?

Back 123

GA is the preferred technique (b/c of the large incision from the pubis to the xiphoid process)

Front 124

In the radical cystectomy, an epidural can be placed to be used in conjunction with the GA. What complications can accompany this?

Back 124

The epidural will cause unopposed parasympathetic control of the bowel causing a contracted bowel making creation of a pouch for urinary diversion difficult.
Glucagon 1 mg IV will help to counteract this effect if it becomes a problem for the surgeon.

Front 125

What are the intraop fluid considerations regarding Retroperitoneal Lymph Node Dissection?

Back 125

An extremely large incision is made to remove all the lymph tissue (from the ureters and the renal vessels to the iliac bifurcation).
The large incision will lead to increases in fluid requirements (there is large third spacing of fluids)

Front 126

Regarding Retroperitoneal Lymph Node Dissection, how is mannitol used to help manage perfusion?

Back 126

Mannitol may be given to increase urinary blood flow and urine production during resection.

Front 127

Regarding Retroperitoneal Lymph Node Dissection, what pts are at highest risk of oxygen toxicity and pulmonary complications?

Back 127

Patients who have been on chemotherapy prior to surgery.
Avoid high FiO2 & get thorough h/o any prior anesthetic complications. (Bleomycin may cause the most damage to lungs).