Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Coexisting conditions > Management of Anesthesia in a Renal pt > Flashcards

Management of Anesthesia in a Renal pt Flashcards

1
Q

If pt is oliguric, what would you expect their GFR to be?

At what GFR do you see reduced clearing of unchanged drugs?

A
  • Oliguric = GFR probably 5-15 ml/min
  • Reduced clarance of unchanged drugs with GFR < 50 ml/min
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is important to know when dosing drugs for pts in renal failure?

Which drugs bind more in chronic renal failure?

A
  • Know Cr clearance/estimated GFR
  • determine VD- Is the ECF increased, decreased, or nml
    • this will effect water soluble drugs
  • protein binding is altered in chronic renal failure
    • acidic drugs bind less, basic drugs bind more
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How will you expect renal failure to affect Atropine and glycopyrrolate?

Scopalomine?

A

potential for accumulation if multiple doses given because 50% is excreted unchanged in urine.

Scopalomine usually not given d/t CNS effects

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How will you expect renal failure to affect benzodiazepines?

A
  • You would use shorter acting benzos and titrate carefully
  • midazolam 60-80% cleared by kidneys in form of active metabolite and highly protein bound
  • start with low dose
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How will you expect renal failure to affect phenothiazines?

A
  • Droperidol
    • has alpha blocking ability- may accentuate hypotension
    • not usually a problem if only small doses given
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

How will you expect renal failure to affect H2 blockers?

A
  • highly dependent on renal excretion
  • metoclopramide will accumulate in renal failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the BEST choice of opioid for a pt in renal failure?

what do you want to avoid?

A
  • fentanyl is best!
  • avoid:
    • morphine- active metab and highly PB avoid repeat dosing
    • meperidine- active metab can cause sz!
    • hydromorphone- active metab accumulates
  • Remifentanyl also ok to use
    • Alfentanyl and sufentanyl- not necessarily bad, but takehome is that fentanyl is the best
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What induction agents should be used with RF?

A
  • TPL- highly PB, free fraction can be 2x normal in pt with RF
  • propofol, ketamine, etomidate- no major clinical changes
    • just might be more sensitive, administer slowly
  • dexmedetomidine- highly PB, longer lasting, low BP not ideal
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What muscle relaxants should be avoided in RF?

A

d-turbo

metocurine

gallamine

pancuronium

piepcurium

doxicurium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Which NMB are ok for one dose but not ideal in a pt with RF?

A

Vec and Roc

about 30% renal excretion; may see prolonged effect

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Which NMB are best for a pt in RF?

Would you want to give succ to apt with RF?

A
  • Atracurium
  • Cisatracurium
  • mivacurium
  • **nml dosing appropriate
  • Use Succ with CAUTION!
    • single dose ok if K is normal
    • DO NOT give if K >5
    • gtt problematic- active metabolite succinylmonocholine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How much can Succ increase a K level?

A

by 0.5-1 mEq/L

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

How will you intubate a pt with RF?

A
  • Avoid Succ
  • Use lidocaine
  • may need beta-blockers to control HTN
  • these pts will have delayed gastric emptying and increased gastric volume
    • consider full stomach protocol with RSI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What should you consider when positioning the pt with RF?

A
  • They are prone to fractures d/t hypocalcemia
  • They are prone to nerve injury d/t uremic neuropathy
  • Distal symmetric mixed motor and sensory polyneuropathy
    • median nerve and common peroneal nerves most often seen
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

How should you provide the maintenance anesthesia for pts with RF?

What if they are hypertensive?

How do you want to ventilate?

A
  • Avoid Halothane and Enflurane d/t free flouride concern
  • Sevo controversial
  • Isoflurand and Desflurane ideal
  • fentanyl combined with N2O, O2, and agent
  • If hypertensive, increase IA or administer NTG or hydralazine
  • Ventilate to maintain normocapnia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Would a renal patient have a accelerated or slowed induction?

A

Accelerated induction AND emergence because of their severe anemia

17
Q

Which way does alkalosis shift the oxy-hgb curve?

A

to the left

less O2 available to the tissues

18
Q

What should you know about the reverasal agents in RF?

A
  • They will have prolonged half lives because they are all heavily excreted renally
    • endrophonium 75%
    • neostigmine 50%
    • pyridostigmine 75%
  • althought effect will be prolonged, it is not a big deal because so is the effect of the relaxants
19
Q

How should you manage the fluids for a pt in RF?

A
  • may need to pre-hydrate, even pts that were jsut dialysed
  • Use NS or 1/2 NS, NO LR!
    • there is debate about this, LR has K in it, NS moves K from ICF to ECF, which is better?!?
  • Use 500 ml bag and micro gtt
  • maintain uop at 0.5 ml/kg/hr
    • lasix 5 mg can be given if uop drops
  • Uop is NOT predictive of postoperative renal insufficiency
  • anuric pts have a narrow margin of safety for fluids
    • may develop CHF or pulm edema post op
20
Q

How do you wnat to monitor a pt in RF?

A
  • Do not measure BP in arm with fistula
  • A-line needed for major cases
  • CVP or PA pressures for cases with a large anticipated fluid shift or EBL
21
Q

What is the benefit of doing regional for a shunt placement?

A

the sympathometic dilation will make it easier for surgeon to place shunt

22
Q

What are the concerns for regional in RF pts?

A
  • if pt has altered mental status from uremic encephalopathy, they may be unable to sit still for procudures
  • coagulopathy concern
  • infection/pH changes will make anesthetic less effective
23
Q

What is better to support CV depression in a pt with RF, fluids or vasopressors?

What are the renal affects of Alpha and beta adrenergics?

A
  • Fluids first!
  • Alpha adrenergics (phenylephrine)- results in greatest interference with renal circulation
  • Beta adrenergics- do not result in renal vasoconstriction, but increase myocardial irritability
24
Q

In septic shock, severe hypotension, etc. renal auto-regulation is impaired. What medication can be renal protective?

A
  • Nor-epi, if it increases MAP > 60 mmHg
25
Q

In Summary,

What are your priorities for GA of a pt with RF?

A
  • schedule surgery for post dialysis
  • NO LR, use K free solution in microdrip tubing
  • Do not use extremity with AV fisutla for BP or IV
  • CV disease likely- A-line, swan
    • maintain preload
  • hypotention
  • Gi prophylaxis
  • Muscle relaxants- use ones with little to no renal elimination
26
Q

How should the RF patient be managed post-operatively?

A
  • recurarizaition can occur due to ineffective metabolism of other drugs (antibiotics)
  • HTN common: NTG or sodium nitroprusside
  • ECG monitoring
  • continue O2
  • antibiotic continuation

Coexisting conditions (34 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions