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160 Cards in this Set

  • Front
  • Back
The kidneys regulate the volume and composition of
body fluids
The kidneys maintain ___, ____ and ____ balance and regulate serum osmolality.
electrolyte, acid/base, extracellular fluid
What do the kidneys conserve?
glucose, amino acids, proteins, water and vitamins
What do the kidneys excrete?
toxins, end products of metabolism
What do the kidneys produce?
erythropoietin, renin, hydroxylation of Vit D to physiologically active form
What nephron parts are in the cortex?
macula densa, distal tubule, proximal tubule, connecting tubule, bowman's capsule, cortical collecting tubule
What nephron parts are in the medulla?
loop of henle (thick ascending, thin ascending, thin descending), medullary collecting tubule, collecting duct
This is the functional unit of the kidney
The ______ reabsorbs 67% of filtrate, which consists mainly of glucose, water, bicarb, amino acids, sodium and potassium.
proximal convoluted tubule
Urine exits via the _____ into the renal pelvis for excretion.
collecting duct
The _____ establishes and maintains the osmotic gradient in the medulla of the kidney. It plays crucial role in establishin the countercurrent multiplier and produces the osmotic gradient.
loop of henle
The osmotic gradient in the corticomedullary region is___ mOsm, and ____ mOsm in the deep medulla.
300, 1200-1500
The _____ and _____ make final adjustments to urine osmolality, pH and ionic composition.
distal tubule and collecting duct
______ controls the reabsorption of H20.
_____ controls the secretion of K.
The kidneys receive ____ % of cardiac output, and filter ____mL/min of plasma.
20-25% (which is 1.25 L/min)
125 mL/min of plasma filtration
How does blood get from the aorta to the glomerulus?
aorta --> renal artery --> interlobar arteries --> arcuate arteries --> interlobar arteries --> afferent arteriole --> glomerulus
To evaluate renal fcn, accurate assessment relies on...
laboratory determinations
Renal impairment may be due to...
- glomerular dysfunction
- tubular dysfunction
- obstruction
The greatest renal derrangements are caused by abnormalities of
glomerular function
The most useful lab tests for kidney fcn are related to...
Ammonia is produced from deamination of _____. The primary source of urea is the ____.
amino acids, liver
Hepatic conversion of ammonia to urea prevents accumulation of
toxic ammonia levels
BUN is directly related to _____ and inversely related to _____.
direct- protein catabolism
inverse- GFR
BUN is not a reliable indicator of GFR unless...
protein catabolism is normal and constant
Normal BUN is
10-20 mg/dL
Creatine, a product of ______, converts to creatinine.
muscle metabolism
Creatinine production is relatively _____ and related to _____.
constant, muscle mass
Creatinine is directly related to _____ and inversely related to ____.
direct- body muscle mass
inverse- glomerular filtration
Is creatinine a reliable indicator of GFR?
Normal male and female creatinine levels?
male- 0.8-1.3
female- 0.6-1.0
GFR declines with _____ yet serum creatinine remains relatively normal.
increasing age
Normal BUN:Cr ratio?
Low renal tubular flow rates enhance _____ but do not affect _____. As a result, ratio will increase above 10:1.
urea reabsorption, creatinine handling
Decreases in tubular flow can be caused by
decr renal perfusion, obstruction
Volume depletion, disorders assoc w decr tubular flow, obstructive uropathies, and incr in protein catabolism will all lead to BUN:Cr ratio of
> 15:1
This is the most accurate method available for clinically assessing overal renal function.
Cr clearance
Normal Cr Clearance is
125 mL/min (110-150)
Cr Clearance measurement is usually performed ___ hrs.
2 or 24
2 hr determinations are accurate and easier to obtain
Cr Clearance in mild renal impairment
40-60 mL/min
Cr Clearance in moderate renal dysfunction
25-40 mL/min
Cr Clearance in overt renal failure
<25 mL/min
This test may be helpful in identifying some d/o's of renal tubular dysfunction.
_____ is related to urinary osmolality and indicative of renal concentrating ability.
Specific gravity
____ is the result of low tubular threshold for glucose or hyperglycemia.
Urine is 95% water....so what makes up the other 5 %???
ammonia, sulfate, phosphate, chloride, magnesium, calcium, K, Na, Cr, Uric acid, urea
What are the renal function tests to determine GFR?
- BUN (10-20)
- Cr (0.7-1.5)
- Cr Clearance (110-150)
What are the renal function tests to determine renal tubular function?
- Urine specific gravity (1.003-1.030)
- Urine Osmolarity (38-140 mOsm/L)
Normal renal function w 100% nephrons functioning will yield a GFR of
125 mL/min
Reduced renal function with 10-40% of nephrons functioning will yield a GFR of
12-80 mL/min
Renal failure with <10% of nephrons functioning will yield a GFR of
<12 mL/min
Essential physiologic functions of the kidney
1 Glomerular filtration
2 tubular reabsorption
3 tubular secretion
2 types of renal failure (Think time!)
acute and chronic
This type of renal failure is classified according to predominant cause or on basis of urine flow rates. It contains prerenal, renal, and postrenal origins.
acute renal failure
What are the 3 urine flow rate classifications in acute renal failure?
-oliguric renal fx
-anuric acute renal fx
-nonoliguric acute renal fx
____ and _____ acute renal failure are readily reversible in initial stages.
prerenal and postrenal
3 Causes of ARF?
- renal ischemia
- nephrotoxins
- intrinsic renal disease
In ______ renal failure, the actual failure of the kidney organ is the primary cause.
What 3 stages is progressive renal failure divided into?
decr renal reserve,
renal insufficiency,
ESRD or uremia
2 main types of dialysis?
HD, peritoneal dialysis
What are the CNS effects of dialytic therapy?
disequilibrium syndrome, muscle cramping
What are the CV effects of dialytic therapy?
hypotension, anemia
What are the resp effects of dialytic therapy?
What are the CV alterations of advanced renal disease?
What are the hematological changes with advanced renal disease?
anemia, prolonged bleeding time
What are the GI effects of advanced renal disease?
incr risk of GI bleeding
What effect does advanced renal disease have on the immune system?
infectious complications common
What are the neuro effects of advanced renal disease?
symptoms correlate to degree of azotemia, seizures assoc w hypertensive encephalopathy
What are the endocrine effects of advanced renal disease?
hyperparathyroidism, adrenal insufficiency
What are the resp effects of advanced renal disease?
pneumonitis, pulm congestion and edema
What electrolyte abnormalities accompany advanced renal disease?
acidosis, Na, Mag, Ca, K
How is hyperkalemia related to advanced renal disease handled perioperatively?
- HD most effective
- insulin and glucose infusion w bicarb
- hyperventilation
- life-threatening dysrhythmias treated w IV CaCl
Describe the pre-op assessment for a renal patient?
- H&P (EKG, CBC, H/H, recent K, CXR)
- dialysis access site
- last HD session
- Labs (Cr Clearance, BUN, Cr, U/A)
_____ is released due to surgical stimulation in normal kidneys, decreasing urine output.
___ is released in normal kidneys during anesthesia due to baroreceptor response to volume depletion.
General anesthesia may affect autoregulation of the kidneys, which usually is impacted when SBP is < ____ mmHg. _____ caused by agents shunts blood away from the kidneys, and a decrease in RBF causes _____ release, leading to renal vasoconstriction.
<80 mmHg,
Most drugs admin perioperatively are at least partly dependent on _____ excretion.
In the presence of renal impairment, what part of your medical regimen must be modified?
dose adjustments!
What effects do barbiturates have on renal pts?
pts w renal disease more susceptible to these agents bc of decr protein binding and more free drug is available to act
What effects do benzos have on renal pts?
most are protein bound so may be more sensitive to these agents; extra caution w valium as active metabolites can accumulate, midazolam 60-80% cleared by kidneys in from of active metabolite and highly protein bound
What is a nice choice for induction? Why not use the others?

thiopental is usually ok but dose must be decr and titrated (less protein binding, w/ acidosis less ionized or bound form)

propofol usually ok but can drop BP

avoid ketamine if pt HTN
What are the considerations for using morphine in renal pts?
6-glucuronide metabolite is active and highly protein bound, so avoid repeat dosing
What are the considerations for using meperidine in renal pts?
avoid due to accumulation of normeperidine metabolite
What are the considerations for using hydromorphone in renal pts?
hydromorphone-3-glucuronide metabolite accumulates, avoid repeat dosing
What are the considerations for using fentanyl in renal pts?
good choice in non-cardiac doses
What are the considerations for using alfentanil in renal pts?
decr protein binding, no active metabolite
What are the considerations for using sufentanil in renal pts?
no change in free fraction but pharmacokinetics unpredictable in CRF
What are the considerations for using remifentanil in renal pts?
remifentanil acid metabolite (minimally active), so no major clinical implications
What are the considerations for using halothane in renal pts?
avoid, high K and acidosis, can lead to myocardial irritability
What are the considerations for using iso/des in renal pts?
volatile agents ideal, no dependence on kidney for elim.
What are the considerations for using enflurane and sevo in renal pts?
compound A and free fluoride ion accumulation - avoid
What are the considerations for using H2 blockers such as pepcid and zantac in renal pts?
highly dependent on renal excretion
Is metoclopramide safe in renal pts?
partly excreted unchanged by kidneys but can accumulate in renal failure, generally safe in a single dose
Are anticholinergics such as atropine and glycopyrrolate safe to use in renal pts?
can be used safely though metabolites may accumulate with repeat dosing
Should you use succ in a renal pt?
safe in pts with K <5.0 mEq/L, but can transiently incr K by 0.5 mEq/L
Why are atracurium and cisatracurium beneficial in renal pts?
metab and excreted through Hoffman elimination and nonspecific esterases -- drug of choice bc does not rely on kidneys!
What are the considerations for using vec and roc in renal pts?
primarily elim in liver but there is some mild prolongation in renal failure
Which paralytics are 60-90% dependent on renal excretion and should be avoided in renal pts?
D-tubocurarine, metocurine, gallamine, pancuronium, pipecurium, doxacurium
What are the considerations for using reversal agents in renal pts?
edrophonium and pyridostigmine (75%) and neostigmine (50%) elim by kidneys -- prolongs half life (at least as much as relaxants they reverse)
What are the 6 types of diuretics?
loop, osmotic, thiazide, carbonic anhydrase inhibitors, aldosterone antagonists, Na channel blockers
Lasix, Bumex, Edecrin, and Demadex are all _____ diuretics, acting in the ascending loop of henle.
loop diuretics
What are the 3 actions of loop diuretics?
- inhibits Na, K, and 2CL-
- diminishes osmotic gradient in the interstitium of the medulla
- reduces amt of water reabsorbed from collecting duct, increasing H20 excretion
What are the adverse effects of loop diuretics?
hypoK, volume deficit, hypotension, reversible deafness
____ is the primary osmotic diuretic, and it acts throughout the renal tubule.
How do osmotic diuretics (mannitol) work?
poorly permeable agent gets trapped in renal tubule --> exerts an osmotic force --> decr reabsorption of H20
What are the adverse effects of mannitol (osmotic diuretics)?
hypoK, rapid expansion of intravascular space --> heart failure
_____ is the primary carbonic anhydrase inhibitor used, and it takes action in the proximal tubule.
acetazolamide (diamox)
How do carbonic anhydrase inhibitors (diamox) work?
inhibits carbonic anhydrase to decr Na and HCO3 reabsorption, causing diuresis
Why are carbonic anhydrase inhibitors (Diamox) given?
to correct metabolic alkalosis
What are the adverse effects of carbonic anhydrase inhibitors (diamox)?
metabolic acidosis through HCO3 loss in urine
______ diuretics work in the distal tubule. Examples include...

HCTZ, chlorothiazide, chlorthalidone, metolazone
How do thiazide diuretics (HCTZ, metolazone) work?
inhibit Na reabsorption in the early distal tubule
What are the adverse effects of thiazide diuretics (HCTZ, metolazone)?
______ diuretics work in the late distal tubule and the collecting duct. Examples include...
aldosterone antagonists,

spironolactone (aldactone), triamterene, amiloride
How do aldosterone antagonists (spironolactone, triamterene, amiloride) exert their effects?
decr reabsorption of Na and decr K secretion by competing for aldosterone binding sites in the distal tubule
What are the adverse effects of aldosterone antagonist diuretics (spironolactone, triamterene, amiloride)?
hyperK due to K-sparing diuretic
_____ diuretics work in the late distal tubule and the collecting duct. Examples include amiloride and triamterene.
Na channel blockers
How do Na channel blockers (amiloride and triamterene) work?
decr Na reabsorption from the late distal tubule and collecting duct
What adverse effects are associated with Na channel blockers (amiloride and trimterene)?
hyperK due to K sparing
What are the preop anesthesia interventions for renal pts?
- identify high risk pts and procedures
- correct fluid losses and hypovolemia
- maintain adequate hydration
- clinical monitoring
What are the intraop strategies for renal pt anesthesia?
- placement of urinary catheter (if not anuric)
- fluid challenge if u/o drops
- renal doses of dopamine
- diuretic therapy w aggressive monitoring and intravascular volume expansion
- prophylactic admin of mannitol or lasix
What are the 4 phases of ARF?
1. onset (initiation phase)
2. oliguric phase
3. diuretic phase
4. recovery phase
What is the anesthesia mgmt strategy once renal failure has been established in the OR?
- maint fluid and electrolyte balance
- early HD during oliguric and diuretic phases
- infection is most frequent complication that can lead to death
What are induction techniques for renal pts?
- avoid succ (unless necessary, IE RSI)
- lidocaine to blunt stimulus
- may need beta blocker to control HTN
- delayed gastric emptying and incr gastric volume, so consider full stomach protocol w RSI
What are maintenance techniques for renal pts?
- short acting opioids w N20/02/inhaled Agent cocktail
- no IV/BP cuff on arm w AV fistula
- monitors: invasive hemodynamic monitoring indicated due to high morbidity group of pts (DM and RF pts have 10x periop morbidity of pts w DM and no RF)
- HTN: manage persistent elevation in BP w incr IA, NTG, or hydralazine
- controlled ventillation good bc decreases risk fo resp acidosis which is not good in setting of metabolic acidosis
What are some intraop fluid mgmt techniques in renal pts?
-pre-hydrate if not dialysis dependent
- LR (has 4 mEq/L of K)
- use 500 mL bgs and microgtt (60 gtts)
- maintain u/o of 0.5 cc/kg/hr
- give 5 mg lasix if u/o drops
In renal pts, intraop. urine output (is/is not) predictive of post op renal insufficiency.
Anuric pts display a ____ margin of safety for fluids, and ____ or _____ may develop post op if not cautious.
CHF or pulm edema
What are the post op mgmt techniques for renal pts?
- EKG, BP, SP02 monitoring
- continue supplemental O2 prn
- continue abx
In _____ the surgeon is able to insert a surgical instrument into the urethra for direct visualization of the internal structures of the bladder.
______ is the most commonly performed urologic procedure, and is indicated for hematuria, recurrent urinary infections, or urinary obstruction.
Types of surgeries performed under cystoscopy:
bladder biopsies, extraction of renal stones, placement of ureteral stents
Pre-op considerations for cystoscopy pts?
standard pre-op eval
Intra-op position and positioning considerations for cystoscopy pts?
lithotomy position

considerations: common peroneal nerve injury, saphenous nerve damage, obturator and femoral nerve injury, sciatic nerve injury, decr FRC w resulting atelectasis, incr venous return exacerbating CHF
What are the 2 options for anesthetic technique for cystoscopy pts?
- General anesthesia w LMA if pre-op eval permits
- regional anesthesia w spinal, local and sedation (local/MAC)
What are the pre-op considerations for TURP pts?
same as cysto- standard pre-op eval
What is the position preferred for TURP cases?
List the 5 major complications assoc w TURP:
1. hypothermia
2. TURP syndrome
3. bladder rupture
4. DIC (released of thromboplastins from prostate into blood stream; if done for CA, tumor may release fibrinolytic enzymes into blood; dilutional thrombocytopenia from absorption and irrigation)
5. septicemia (open sinuses allow bacteria to enter bloodstream)
For a TURP procedure, a _____ is inserted in the urethra, down into the bladder and to the prostate gland for resection.
This complication can occur intra or post op in TURP cases, and is caused by systemic absorption of irrigation fluid through open prostate sinuses.
TURP syndrome
What are awake and anesthetized pt s/s of TURP syndrome?
awake: headache, restless, confused (hypoNa, H20 intoxication), cyanosis, dyspnea, arrhythmias, hypotension, seizures (HypoNa, H20 intox)
sleeping: hypo-osmolality, fluid overload (CHF, pulm edema), hemolysis
How do I treat Turp syndrome?
- early recognition and tx critical
- supportive care to avoid hypoxemia and hypoperfusion
- H20 restriction and loop diuretic to remove excess fluid
- symptomatic hypoNa leading to seizures/coma needs hypertonic saline (3% NaCl no faster than 100 mL/hr)
What are the 2 possible anesthesia techniques for TURPs?
- regional: spinal or epidural depending on length of procedure
- general: LMA if pre-op eval appropriate
This type of urosurgery involves shock waves used to break apart a kidney stone to allow for passage through the urethra. Newer machines employ gel pads to conduct the shock waves into the body, and older machines employed a submersion tank w H20.
extracorporeal shock wave lithotripsy (ESWL)
What are the preop considerations for ESWL?
- pts w heart dz and implantable devices (pacers or AICDs) need further eval, as ESWL more likely to cause arrhythmias in these pts
During ESWL, it is important to control the heart rate because...
- better results
- shock wave timed w EKG to avoid causing arrhythmias
- number of shock waves is dependent on number of heart beats/min (slower HR = lower # of shock waves/min; and fast HR = incr risk of causing arrhythmias due to inaccurate shock wave w EKG)
What were the effects of ESWL immersion?
- hot water bath can lead to vasodilation and hypotension initially
- compression of peripheral vasculature by pressure of H20 can lead to incr venous return (distrib of blood to thoracic compartment) which will incr SVR and decr CO
- incr in blood in central compartment leads to exacerbation of CHF
- incr intra-thoracic blood volume reduces functional residual capacity by 30-60% and predisposes to hypoxemia
What are the 3 options for anesthetic plan for ESWL pts?
1. regional: spinal or epidural (epidural better bc allows for re-dosing during long procedure), avoid placing too much air in epidural space during placement bc air dissipates shock wave and lowers efficacy
2. General: ETT bc pt is placed in H20 - more secured airway
3. MAC w sedation
What are the monitoring considerations during ESWL?
secure EKG w water proof drsgs if being immersed in H20 (EKG necessary to properly time shockwaves)
What are the fluid management techniques recommended in ESWL?
- large amts of fluid required to ensure adequate urine production and flow to remove debris from kidney stone
- lasix can be given in conjunction to fluid to incr u/o
This is the removal of the prostate due to CA
radical prostatectomy
Intra-op considerations for radical prostatectomy?
- large blood loss (EBL 300-500 mL) due to vascular nature of prostate and approach to remove it
- A-line recommended for frequent lab draws (Due to blood loss) and more closely monitor BP if hypotensive
- neck of bladder is removed during procedure (will lose u/o from catheter during this period)
- indigo carmine useful to help identify ureters during resection
- prepare for transfusions from blood loss (large IV access, T&C pre op)
- maintain u/o (may be temporarily anuric during construction of urinary pouch after removal of bladder)
- permissive hypotension to decr blood loss
Choices of anesthetic plan for radical prostatectomy?
1. regional: epidural possible but will require large amts of sedation; will cause unopposed parasymp. control of bowel causing contracted bowel (makes creation of pouch difficult for urinary diversion)
2. general: allows for better control of airway in trendelenberg, preferred, large incision from pubis to xiphoid process
_____ requires 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 op.
Urinary diversion
During retroperitoneal lymph node dissection, there is an extremely large incision used to remove all lymph tissue from the _____ and ____ to the iliac bifurcation.
ureters, renal vessels
During retroperitoneal lymph node dissection, large incision size will lead to incr in ______ due to third spacing of fluids.
fluid requirements
During retroperitoneal lymph node dissection, _____ may be given to incr urinary blood flow and urine production duing resection around renal blood supplies.
During retroperitoneal lymph node dissection, chemo pts will be at higher risk for ______ and _____, so high Fi02 should be avoided.
O2 toxicity, pulm complications
During retroperitoneal lymph node dissection, there is risk of damage to the _____artery, so Proper neuro exam is required prior to use of regional.
artery of adamkiewicz
During retroperitoneal lymph node dissection, pain control is very _____. The 2 pain mgmt techniques most appropriate are...

epidural cath to improve post op pain control, narcotic PCA required if not using epidural