Advanced Principles EXAM2

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Android (Central) Obesity is more centrally located (abdomen/upper body). Men waist circumference> ____. Women waist circumference > ____.Men >40" Women >35"Android (Central) Obesity has an increased incidence of _____.Cardiovascular diseaseMetabolic syndrome related to Android (Central) obesity includes what 3 components?1. HTN 2. Obesity 3. DMII Central Obesity has an overall increased morbidity and mortalityMetabolic syndrome is thought to be the result of fat breakdown being delivered directly into ______ where it produces a metabolic imbalance.portal circulationCo-Existing respiratory conditions associated with Obesity include what 5 pathologies?1. Restrictive Lung Disease 2. Asthma 3. Obstructive Sleep Apnea 4. Obesity Hypoventilation Syndrome 5. Pickwickian SyndromeCo-Existing Cardiovascular conditions associated with Obesity include what 9 pathologies?1. HTN 2. Cardiomegaly 3. CHF 4. CAD 5. PVD 6. Pulmonary HTN 7. Thromboembolism 8. Stroke 9. Sudden DeathCo-Existing Endocrine/Metabolic conditions associated with Obesity include what 4 pathologies?1. DMII 2. Cushing's Syndrome 3. Hypothyroidism 4. HyperlipidemiaCo-Existing Gastrointestinal conditions associated with obesity include what 4 pathologies?1. Hiatal Hernia 2. Ventral Hernia 3. Fatty Liver 4. Cholelithiasis (3 fold)Co-Existing Musculoskeletal conditions associated with obesity include what 2 pathologies?1. Osteoarthritis on weight bearing joints 2. Low Back Pain5 Co-Existing Malignancies associated with Obesity?1. Breast 2. Prostate 3. Cervix 4. Uterine 5. ColorectalCo-Existing psychiatric conditions associated with obesity include what 2 pathologies?1. Depression 2. Low self-esteemEstimated blood volume (EBV) in obese patients is ____ml/kg TBW50 ml/kg TBWObesity results in an increase of _____ L/min/kg for each kg of adipose tissue perfused.0.1 L/min/kgObesity results in _____ secondary to an increased afterload. Left ventricular hypertrophy progresses to a noncompliant left ventricular that leads to _____.Systemic HTN CHFObesity can result in pulmonary HTN secondary to increase in pulmonary blood volume.Chronic Hypoxemia secondary to obesity leads to _____.Hypoxic Pulmonary Vasoconstriction (HPV)Right ventricular hypertrophy secondary to obesity leads to _____.Cor PulmonaleObese individuals are at 2 times the risk of ____ than non-obese individuals.Coronary Artery DiseaseObesity can result in _____ secondary to the metabolically active adipose tissue. This causes an increase in ____ & _____.Arterial hypoxemia oxygen consumption and CO2 productionObese individuals have a(n) INCREASED/DECREASED/NORMAL PaCO2.Normal this is because of an increase in alveolar ventilationObesity creates a(n) OBSTRUCTIVE/RESTRICTIVE ventilatory pattern.RestrictiveThe restrictive ventilatory pattern of obese individuals is related to what 4 things?1. Decreased chest wall compliance 2. Increased abdominal mass 3. Decreased diaphragmatic excursion 4. Increased work of breathingObesity results in a decrease in what 5 lung volumes?1. FRC (functional residual capacity) 2. VC (vital capacity) 3. IC (inspiratory capacity) 4. ERV (expiratory reserve volume) 5. TLC (total lung capacity)These lung volumes are unchanged in obesity (3)1. VT (tidal volume) 2. FEV1 3. RV (residual volume)The volume in the lungs at which its smallest airways, the respiratory bronchioles, collapse.Closing VolumeClosing volume is DELAYED/REACHED FASTER in obesity.reached fasterRespiratory changes in obesity include an increased ____ and decreased ______.increased demand and decreased supply3 components of increased demand (metabolic demands of "fat organ") of obesity1. Increased O2 consumption 2. Increased CO2 production 3. Increased alveolar ventilationDecreased supply (abdominal and chest wall fat) causes a decreased chest wall compliance that results in what 7 things?1. Decreased lung volume 2. Decreased FRC 3. Premature airway closure 4. V/Q Mismatch 5. Arterial hypoxemia 6. Increased work of breathing 7. Decreased respiratory muscle efficiency_____ is common in obese patients (50%)Obstructive Sleep ApneaObstructive sleep apnea is obstruction of the _____ during sleep.upper airwayHypopnea is a 50% reduction in airflow related to sleep apnea that causes a decrease in SaO2 by ____%4%Apnea is defined as > ___ second cessation of airflow despite continued respiratory effort against a closed airway.10secondsObstructive sleep apnea has an increased risk of what 5 perioperative complications.1. Prone to respiratory depressant effects secondary to benzodiazepines/opioids 2. Hypoxia 3. HTN 4. Difficult airway 5. Postop airway obstruction -CPAP_____ is a central hypoventilation that occurs in the super-obese (>50kg/m^2). It results in a more restricted pulmonary function that OSA.Obesity Hypoventilation SyndromeWhat is central hypoventilation?Progressive desensitization of the brain's respiratory center to hypercapnia5 Manifestations of Obesity hypoventilation syndrome?1. Somnolence 2. Cardiac Enlargement 3. Polycythemia 4. Hypoxemia 5. HypercapniaMost severe form of Obesity hypoventilation syndromePickwickian Syndrome6 Manifestations of Pickwickian Syndrome1. Hypersomnolence 2. Severe hypoxia 3. Severe hypercapnia 4. Pulmonary HTN 5. Right/Bi ventricular enlargement (cor pulmonale) 6. Blunted respiratory drive -Rely on hypoxic ventilatory drive -Hypoventilate/apneic following general anesthesia or 100% oxygen5 Gastrointestinal changes related to obesity1. Increased intra-abdominal/gastric pressure 2. Increased gastric volume (>25ml) -delayed gastric emptying 3. Decreased gastric pH (<2.5) -increased gastrin & parietal cell secretion 4. Hiatal hernia 5. GERD3 Hepatic changes related to obesity1. Non-alcoholic steatohepatitis (NASH) 2. Increased cholesterol 3. Increased triglycerides"fatty hepatitis" with or without liver dysfunction.Non-alcoholic steatohepatitisIn Non-alcoholic steatohepatitis (NASH) LFT's are abnormal but may not reflect the actual severity of the disease. _____ is the most frequently elevated enzyme.ALTIn obesity, an increased uptake of what volatile agent is thought to cause hepatitis?Halothane Increased metabolism and a predisposition to hypoxia may explain the increased incidence of halothane hepatitisObesity puts an individual at increased risk for what endocrine change?Type II DM -resistance of fatty tissue to insulin -impaired insulin-related suppression to hepatic glucose production -decreased glucose utilization -impaired glucose tolerance -hyperglycemia -hyperinsulinemiaDMII related to obesity puts individuals at increased risk for _____. These patients may require perioperative _____ to oppose catabolic response to surgery.poor wound healing periop insulinProlonged obesity can cause a loss of nephron function related to ________.glomerular hyperfiltration (increased plasma flow and GFR)Predicting behavior of anesthetic drugs is difficult in the obese population. Complexity of drug pharmacokinetics in the obese patient include what 5 components?1. Variations in Vd 2. Alteration in renal clearance 3. Altered hepatic metabolism 4. Concomitant disease state 5. Limited evidence-based data this creates a dilemma for the anesthesia providerLipophilic drugs in the obese population causes an INCREASED/DECREASED volume of distribution.increasedVolume of distribution =dose/drug concentrationAn increased Vd for lipophilic drugs in obesity is related to a(n) INCREASED/DECEASED total body volume and fat stores, a(n) INCREASED/DECREASED plasma concentration, a(n) INCREASED/DECREASED elimination 1/2 life and INCREASED/DECREASED clearance1. Increased total body volume and fat stores 2. Decreased plasma concentration -initial or loading dose INCREASED 3. Increased Elimination 1/2 life or decreased clearance -Maintenance dose DECREASEDFor lipophilic drugs in obesity the maintenance dose is INCREASED/DECREASEDDecreased this is due to an increased elimination 1/2 life or decreased clearanceFor lipophilic drugs in obesity the induction or loading dose is INCREASED/DECREASEDIncreased this is due to decreased plasma concentration (chronic dehydration)Excess adipose tissue results in low blood flow which leads to a(n) INCREASED/DECREASED plasma concentration of lipophilic drugs if the dose is calculated on TBWincreased accumulation of infusions/repeated doses=prolonged durationDosing guidelines for lipophilic drugs recommend calculating the initial dose on ____. Exceptions to these guidelines include ___ & ____.TBW Propofol and RemifentanilDosing guidelines for lipophilic drugs recommends calculating maintenance dose on ___IBWThiopental's induction dose is based on ____.TBW highly lipophilic-->larger Vd increased TBV, CO, and muscle massPropofol's induction dose is based on ___IBW clearance and Vd at steady high affinity for excess fatMidazolam's loading dose is based on _____TBW a higher loading dose (TBW) required to achieve adequate serum levels. -highly lipophilic --> larger Vd prolonged durationFentanyl/Sufentanil's induction dose is based on ____TBW increased induction dose highly lipophilic --> larger Vd distributes extensively in excess body massFentanyl/Sufentanil's maintenance dose is based on ______IBW increased elimination 1/2 lifeRemifentanil is dosed on _____IBW Vd less (hydrolysis by blood/tissue esterases)Hydrophilic drugs = INCREASED/DECREASED/NO CHANGE in Vd in obesityNo change more limited Vd not influenced by fat storesHydrophilic drugs may have a prolonged duration if reliant on _____ metabolism.hepaticDuration of action for hydrophilic drugs unchanged if dependent on ______Hoffman's eliminationThe hydrophilic drugs Vecuronium and Rocuronium are dosed based on ____ to avoid overdosing.IBW or dosed based on adjusted body weight ABW=IBW + 0.4 (actual weight-IBW)The hydrophilic drugs Cisatracurium and Atracurium are dosed based on ____TBW organ independent eliminationDosing guidelines for the hydrophilic drug Succinylcholine is ___ mg/kg of ____.1mg/kg of TBW increased pseudocholinesterase activity increased TBVWhich inhalation agent is least likely to be used in the obese population due to its hepatic metabolism (20%) and high fat:blood coefficient (56)?HalothaneHypoxemia related to obesity when paired with halothane leads to a hepatotoxic reductive pathway resulting in _____"Halothane Hepatitis"Halothane has a ___ fat:blood coefficient of ___high 56Isoflurane has a ____ rate of hepatic biodegradation, lack of ______, and a ___ fat:blood coefficient of ____.low rate of biodegration (<0.2%) lack of nephrotoxicity High fat:blood coefficient of 45Sevoflurane has minimal biodegradation (2%) but has potential nephrotoxicity due to _____.increased fluoride concentration unsuitable with marginal renal functionSevoflurane has a _____Fat:blood coefficient of ____High 48Nitrous Oxide has a ____ Fat:blood coefficient of ____LOW (insoluble) 2.3 (rapid onset/decrement) minimal metabolism (0.002%)Which inhalation agent is an analgesic but is limited in use by its need for higher FiO2Nitrous OxideProbable agent of choice for obesity due to its low rate of hepatic degradation (0.02%), low fat:blood coefficient of 27, fastest emergence time, and fewer postoperative respiratory events.DesfluraneIn order from highest to lowest, rank the inhalation agents by fat:blood coefficientHalothane (56)>Sevoflurane (48)> Isoflurane (45) > Desflurane (27) > Nitrous Oxide (2.3)Preoperative evaluation in obesity should focus on _____associated co-morbiditiesCardiac comorbidities associated with Obesity include what 3 things?1. HTN 2. CAD 3. R&L ventricular failureRespiratory comorbidities associated with Obesity include what 2 things?1. OSA 2. Airway abnormalitiesMetabolic comorbidities associated with Obesity include what 3 things?1.DM 2. Liver function 3. RenalGI comorbidities associated with Obesity includes what 2 things?1. GERD 2. Hiatal HerniaWhat abnormalities might be present on an obese patient's CBC and Electrolytes?1. Increased WBC-->hidden infection 2. Increased HCT-->chronic hypoxemia 3. Increased HCO3-->buffer chronic respiratory acidosis for CO2 retentionWhat abnormalities might be present on an obese patient's ABG?Hypoxemia Hypercarbia CompensationWould you order PFT's and LFT's on an obese patient?No, not found to be cost effectiveWould you order a CXR on an obese patient?1. Only if history suggests it may offer additional information 2. Cardiomegaly/underlying lung disease/prominent pulmonary arteryWhat would you expect to see on an Obese patient's ECG?1. Atrial/ventricular enlargement 2. Arrhythmias 3. IschemiaA ____ is beneficial in providing some measure of an obese patient's baseline respiratory function.pulse oximetryCAUTION using ____ & ____ preoperatively in obese patient's due to increased respiratory depressant effect.Benzodiazepines and OpioidsAVOID Benzodiazepines & Opioids in obese patients with _____, _____, _____.Hypoxemia, hypercarbia, OSA (especially if central)Obese patient's benefit more than the general population from premedication with _____, ____, & ____ for aspiration prophylaxisH2 antagonist Prokinetic (Metoclopramide) Nonparticulate antacid (Bicitra)Premedication with ____ is beneficial in obesity if an awake fiberoptic intubation is planned.Glycopyrrolate_____ prophylaxis is beneficial in obesity due to an increase rate of wound infections.Antibiotic______ prophylaxis is beneficial because morbid obesity is a major independent risk factor for sudden death from acute pulmonary embolism.DVT4 Risk factors for developing postoperative DVT1. Venous stasis 2. BMI > 60 3. Truncal obesity 4. Obesity hypoventilation syndrome/Obstructive sleep apneaDVT prophylaxis includes what 4 things1. Heparin 5000 units SQ 2. LMWH 3. Compression Stockings 4. Consider IVC filter placement preop if high risk present4 Positioning concerns related to Obesity1. Specialty OR table required Regular max wt 205kg "Hercules" max wt 455kg extra width 2. Protect Pressure Points 3. Supine/T-burg further decreases FRC 4. Reverse T-burg best before inductionAVOID _____ and ____ position in obesity if not mechanically ventilated and add ____ due to decrease in FRC.Supine and T-burg PEEPWhat two mechanisms of putting the patient in reverse T-burg before induction makes it desirable?1. Uploads diaphragm/Maximizes FRC 2. Decreases venous return and COProper fitting BP cuff is difficult in obesity. Cuff must encircle a minimum of ___% of the upper arm circumference. If it's too small it results in a false ____ BP.75% HighObtaining a forearm BP measurement with a regular size cuff results in ____.overestimation of both SBP & DBPWhen is an arterial line necessary?1. Evidence of cardiorespiratory disease 2. Unable to get cuff workingObesity can result in difficulty obtaining venous access. What might you consider in these patients?Central Line placementObesity can cause a difficult airway. Fatty tissue distribution through the neck, thorax, and chest limits ____, _____, and shortens ____.neck extension temporalmandibular mobility (small mouth opening) Shortened thyromental distance____ is identified as the single best predictor of problematic intubation.Airway neck circumference 5% probability>40cm 35% probability>60cmObesity can cause difficulty mask ventilating due to _____excessive pharyngeal tissue/large tongue (high mallampati score)Using an LMA in obesity puts the patient at increased risk for _____.aspirationUnder General Anesthesia the obese patient will HYPO/HYPERventilate without assistancehypoventilateIf you are convinced the obese patient will be an easy intubation it is ok to proceed with _____RSI with CCPFor suspected difficult intubation related to obesity a(n) ____ is necessary.awake fiberoptic intubationObese patients are put in the ____ position for intubation because it compensates for exaggeration of neck flexion and aligns the oral/pharyngeal/ laryngeal axis."stacking" -elevate head/shoulders above chestWhat is the "HELP" position?Head Elevated Laryngoscopy Position -Preformed head elevation pillow -Easier, more superior to stacking -Expensive____ position provides the longest "safe apnea period"Reverse T-burg with head-up positionPreoxygenation is vital in obesity. ____VC breaths of 100% oxygen over ____seconds proven superior in obese. Applying ____ prevents atelectasis.4 VC over 30 Seconds positive pressure ventilationIn obesity ____+____=rapid desaturation/apnea/loss of consciousnessIncreased oxygen consumption + decreased FRCVentilatory management of obesity includes keeping the FiO2 ___%, ____ tidal volume of ____ ml/kg IBW, and PEEP< ___cm H2O.FiO2 >50% Larger tidal volume of 10-12ml/kg IBW PEEP <15cm H2OA larger tidal volume in obesity counters the decrease in ___ & ___. >___ml/kg offers no advantage due to increased PIP, end-expiratory airway pressure, and lung compliance without significantly improving oxygen tension.FRC & PaO2 13ml/kgOnly ventilatory parameter shown to consistently improve respiratory function in obese.PEEPCAUTION PEEP in extremely obese patients with ____pulmonary HTNEstimated blood volume in obesity50ml/kg increase in TBV, however, percentage per total body weight is lessVolume replacement in obesity should take into consideration what 3 things?1. Use reduced parameters (ABW/IBW) 2. AVOID rapid rehydration -lessen cardiopulmonary compromise 3. Guide by BP/HR/Urine outputVolume expanders in obesity should be <____ml/kg IBW due to concern for overload.20Local anesthetic requirements in obesity is ____ by 20-25%reduced Epidural vein engorgement and fatty infiltrates cause a decreased volume of epidural space leading to a higher spread and level.Advantages of Regional Anesthesia in obesity include what 5 components?1. Surgical anesthesia and postop analgesia 2. Decreased incidence of postop respiratory compromise NOTE: delayed respiratory depression is a known complication of central neuroaxial opioids 3. Less CV stress/O2 consumption 4. Prevention of DVT 5. Early ambulationDisadvantage of Regional AnesthesiaTechnically Difficult4 Requirements of Extubation in obesity1. Awake, alert, following command 2. Airway reflexes intact 3. Adequate reversal NMB 4. Respiratory Rate <30 breaths/min5 indications of adequate reversal of neuromuscular blockade1. Sustained tetany with post tetanic facilitation of twitches 2. Sustained head lift >5 seconds 3. Inspiratory force -25 to -35 cm H2O 4. PaCO2 < 50mmHg 5. Vt >5ml/kg IBWIf SaO2 values of concern prior to extubation obtain an ABG on ___% FiO2. Want PaO2 > ___mmHg and PaCO2 < ____ mmHgABG on 40% FiO2 -PaO2 >80mmHg/PaCO2<45-50 mmHgConsider a delayed extubation in what 3 situations?1. Difficult intubation 2. Baseline respiratory compromise preop 3. Prolonged surgery with significant fluid shifts____ during transport to PACU and ___ position unloads the diaphragm improving ventilation and oxygenation after extubation of the obese patient.Supplemental oxygen Sitting5 Postoperative complications in the obese patient include?1. Hypoxia/atelectasis 2. Airway obstruction 3. Ventilatory depression (opioids) 4. Thomboembolism (DVT-->PE) 5. Wound infectionIn the case of hypoxia and atelectasis postoperative place the obese patient in the ____ position and provide ____.sitting supplemental oxygenIn the case of airway obstruction postoperative in the obese patient place the patient on ____CPAP______ from opioids is a common postoperative complication especially in OHS and PickwickianVentilatory depression____ population is the fastest growing.Geriatric In 2000: > 65 yo-->13% population >85 yo-->1.25% By 2040: >65 yo-->24% populationGeriatrics account for ___% of the national health care cost50%50% will REQUIRE surgery despite 3-fold increased risk for perioperative complications due to what 2 things?1. Reduced functional reserve 2. Higher Incidence of coexisting diseases NOTE: Age alone is only a minor predictor for perioperative risk.There is no current consensus as to when the "Geriatric Era" begins. There is no single physiologic marker to identify the "physiologically elderly" patient. There is interindividual variability in rate of organ function change. Change is significantly altered by ____, ____, ____, & ____.activity level social habits diet genetic backgroundDefine what it means to be "physiologically younger" .Maintain greater than average organ functional capacities.Define what it means to be "physiologically older".Organ function declines at an earlier age than usual or at a more rapid rate.Elderly is considered >/= ____ years old65Aged is considered >/= _____ years old80The difference between minimal and maximal organ system function or the "safety margin" of organ capacity available to meet additional demands made on the organ system (stress, disease, etc.)Organ system "functional reserve""Functional reserve" is progressively and significantly INCREASED/DECREASED in the elderly population.DecreasedThe elderly have increased susceptibility to stress and disease induced ______organ system decompensationPeople are never more alike than they are ______, nor more different or unique than when they birth enter the geriatric era______ & _______ of the elderly surgical patient represents a great challenge to all medical health care providers.Precise assessment and appropriate perioperative managementOptimal anesthetic management of the elderly depends on an understanding of normal changes in ______ & ______and response to ______.physiology and anatomy pharmacological agentsIt is important to distinguish between ______ changes in physiology that accompany aging and the ______ common in the geriatric population."normal" pathophysiology of diseasesCardiovascular changes in the geriatric population include what 6 things?1. Decreased arterial elasticity/compliance 2. Decreased adrenergic activity 3. Decreased Myocardial responsiveness to catecholamine's 4. Decreased Cardiac Output 5. Reduced compliance of the venous capacitance system 6. Conduction abnormalitiesDecreased arterial elasticity/compliance in geriatrics causes ____, _____, _____, & _____.Increased SBP (DBP unchanged or decreased) Increased SVR LVH Diastolic dysfunctionLVH & diastolic dysfunction in geriatrics is related to a _____which decreases compliance, impairs diastolic filling, increases EDV (SV), increases LVEDP, increases LAP (afib/aflutter), and increases pulmonary pressures."Stiffened myocardium"With LVH & diastolic dysfunction in geriatrics ______ becomes more important with decreasing compliance due to decreased early diastolic filling of ventricles.Atrial kickLVH & diastolic dysfunction in geriatrics results in increased wall tension which increases ______ and causes and increased risk for ______.myocardial O2 demand myocardial ischemiaThe geriatric patient is prone to ____ with _____ due to decreased arterial elasticity and compliance that results in LVH & diastolic dysfunction.CHF with fluid overloadDecreased adrenergic activity associated with geriatrics causes a(n) INCREASED/DECREASED maximum attainable heart rate, a(n) INCREASED/DECREASED resting heart rate, and impaired baroreceptor reflexes.Decreased maximum attainable HR Decreased resting HRGeriatrics have a decreased maximum attainable HR due to decreased sensitivity of _______ receptors. There is a decrease of ____beat/min per year over the age of 50. This results in a decreased likelihood of an increase in CO by increasing HR.Adrenergic 1 beat/min per year after 50Geriatrics resting HR decreases due to an increase in _____.vagal toneBaroreceptor reflexes are impaired in geriatrics because of a decrease in baroreceptor sensitivity and autonomic dysfunction. _______ is common with hypovolemia, position, anesthetic depth, and regional induced sympathetic blockade.HypotensionThe decrease in myocardial responsiveness to catecholamines in geriatrics is related to physiologic _____ with little change in ______ or ______ activity.B-blockade alpha-adrenergic or muscarinic activityCardiac output decreases ____% per decade due to decreased ______.5% decreased metabolic demandsReduced compliance of the venous capacitance system in geriatrics is related to a decrease in _______ & a reduced ability to ______.decrease in "vascular reserve volume" reduced ability to "buffer" changes in intravascular volumeConduction abnormalities in geriatrics are related to _____ & ______.fatty infiltration & fibrosis myocardiumAnesthetic implications include remembering that the elderly are less capable of defending there ____ or ____ against usual perioperative challenges & prolonged _____.Cardiac output or BP prolonged circulation time These perioperative challenges include anesthesia induced vasodilation, blood loss, position changes, physiologic stress of surgery, increased metabolic demands (shivering, sepsis)Prolonged circulation in geriatric patients is related to what 2 things?1. Delayed onset of IV anesthetic 2. Increased induction rate with volatile agentsRespiratory changes in geriatrics includes what 4 things?1. Decreased elasticity of lung tissue 2. Chest wall changes 3. Blunted response to hypoxia & hypercarbia 4. Decreased protective laryngeal reflexesDecreased elasticity of the lungs in geriatrics results in a decrease in ____ & _____ and an increase in _____,_____,_____, & _____.Decrease in alveolar surface area and PaO2 Increase in PAO2-PaO2 gradient (lower arterial O2 concentration), residual volume, closing volumes/capacity, and FRCDecreased alveolar surface area in geriatrics is a result of _____ that leads to overdistention of alveoli, collapse of small airways, and decreased gas exchange.increased compliancePaO2 drops_____ mmHg/year after age 20.0.35 mmHg/yearThe PaO2 for a given age =102 - age/3PAO2-PaO2 gradient calculation0.21 (age+25)Smokers, elderly patients, and patients with chronic lung disease WILL experience airway closure within _____, and this is recognized by the presence of a ______. This is extremely important because anything that adversely affect airway girth (bronchospasm, edema, inspissated mucus, foreign objects), or lung compliance (lung volume-interstitial edema or fibrosis), will increase the ____ or reduce the ____.tidal breathing hyperinflated chest increase the closing volume or reduce the FRCA decrease in the elasticity of lung tissue in geriatrics results in a decrease in _____ & _____, an increase in ______,V/Q mismatching, decreased gas exchange, _____ like changes with a(n) ______ pattern.decrease in VC & FEV1 increase in physiologic and anatomic deadspace Emphysema like changes Obstructive pattern_____ &______ in geriatrics is a result of blunted response to hypoxia and hypercarbia.Irregular breathing patterns and transient apneaWhat 3 chest wall changes occur in geriatrics?1. Decreased respiratory muscle mass 2. Increased chest wall rigidity 3. Restrictive PatternA decreased respiratory muscle mass in geriatrics results in an increased ______ & a decreased ______.increased work of breathing decreased maximal minute ventilationIncreased chest wall rigidity in geriatrics results in a decrease in what 3 things?1. Diaphragmatic movement 2. Chest excursion 3. Ability to cough/clear secretionsGeriatric population is prone to _____ due to decreased protective laryngeal reflexes.aspiration2 Anesthetic implications related to geriatric respiratory changes1. Prevention of perioperative hypoxemia 2. Postoperative respiratory failure commonPrevention of postoperative hypoxemia in geriatrics includes what 4 interventions.1.Higher inspired oxygen concentration 2. Longer preoxygenation prior to induction 3. PEEP 4. Aggressive pulmonary toiletBecause postoperative respiratory failure is common in geriatrics postoperative _____ may be required. ______ should also be considered for postoperative pain control.mechanical ventilation Regional (epidural LA/narcotics, nerve blocks)Central Nervous system changes in geriatrics include what 3 things?1. Decrease in brain mass & progressive neuronal loss 2. CBF decreased by 10-20% in proportion to neuronal losses (autoregulatory responses to BP, CO2, and O2 are maintained) 3. Decreased synthesis of neurotransmitters and there receptorsPeripheral Nervous System changes in geriatrics include what 2 things?1. Degeneration of peripheral nerve cells 2. Increased threshold for nearly all sensory modalitiesDegeneration of peripheral nerve cells in geriatrics results in prolonged ________, decreased ______, loss of ______, and further impairment of _____.prolonged conduction velocity decreased skeletal muscle strength loss of fine motor control further impairment of CV reflexesThere is an increased threshold for nearly all sensory modalities in geriatrics including touch, temperature, proprioception, hearing, and visual. However, there is a decline in ____________density of pain-sensing Meissner's corpuscles in skinRenal function changes in geriatrics includes a decrease in what 5 things?1. Renal mass (especially cortex) 2. Renal blood flow (50%) 3. Glomerular filtration rate 4. Creatinine clearance 5. Ability to correct alterations in electrolyte concentrations, intravascular volume and free waterWhat is the most sensitive indicator of renal function in the elderly?Creatinine clearanceGeriatrics reduced ability to correct alterations in electrolyte concentrations, intravascular volume, and free water include impaired _____, _____, & _____.Impaired sodium handling Impaired concentrating ability Impaired diluting capacityAnesthetic implications for renal function changes in geriatrics include what 4 things?1. Increased risk for intraoperative fluid and electrolyte disturbances 2. Increased risk for acute renal failure 3. Proper fluid management of fluids and electrolytes is critical 4. Decreased drug excretionWhat are the main intraoperative fluid and electrolyte disturbances related to renal function changes in the elderly.Dehydration or Fluid overload Hyperkalemia or HypokalemiaUrine output in geriatrics should be maintained at least ____ ml/kg/h0.5 ml/kg/hFor procedures with major fluid shifts or loss ____ should be monitored in geriatrics.Cardiac filling pressuresDecreased drug excretion in geriatrics results in a prolonged ______ & ______elimination 1/2 life and duration of actionHepatic function changes in geriatrics includes what 6 things?1. Decreased liver mass 2. Decreased hepatic & portal blood flow 3. Decreased hepatic function (reserve) 4. Decreased albumin production 5. Decreased plasmacholinesterase levels (Men>Women) 6. Hepatic enzyme activity unchanged vs. declinedThe rate of drug ______ decreases in relation to hepatic function changes in geriatrics.drug biotransformationAnesthetic implications related to hepatic function changes in geriatrics include what 2 things?1. Slower drug metabolism 2. Low albumin leads to more drugs available for receptor binding (higher drug sensitivity)6 Metabolic function changes related to geriatrics1. Basal metabolism and maximal oxygen consumption decline 2. Decreased heat production 3. Increased heat loss 4. Blunted central thermoregulation and body composition changes (decreased muscle mass, increased lipid fraction) 5. Increased propensity for intraoperative hypothermia 6. Increased insulin release (unable to handle glucose loads)Pharmacokinetics (what the body does to the drug) in geriatrics is related to a decrease in______ & _______Decrease in muscle mass + increase of body fat= decrease in total body water Decrease albuminA decrease in muscle mass, increase in body fat, and decrease in TBW in geriatrics increases Vd for ___-soluble drugs and decreases Vd for ___-soluble drugs.Increased Vd=lipid-soluble Decreased Vd=water-solubleAn increased Vd for lipid soluble drugs causes a ____ plasma concentration and _____ elimination (duration)lower plasma concentration prolongs eliminationA decreased Vd for water-soluble drugs causes ____ plasma concentration.higherA decrease in albumin reduces _____ of anesthetic drugs and increases free unbound drug in plasma _____ the effect.reduces protein binding enhancingPharmacodynamics (what the drug does to the body) in geriatrics causes an age-related _____ in both inhalation and intravenous anesthetic requirements.reductionMAC of inhalation agents decreases ____% per decade after age 404%Onset of inhalational anesthetics is MORE/LESS rapid if cardiac output is decreasedMoreOnset of inhalational anesthetics is QUICKER/DELAYED if V/Q mismatching is present.DelayedInhalational agents cause an GREATER/LESS myocardial effect in geriatrics.GreaterProlonged recovery from inhalational agents in geriatrics is due to what 3 things?1. Decreased pulmonary gas exchange 2. Increased body fat 3. Decreased hepatic function (halothane metabolism)Geriatrics have an enhanced sensitivity and prolonged duration to these IV anesthetic due to slower redistribution from the central compartment to the rapidly equilibrating peripheral compartment.BarbituratesGeriatrics require a ____to____% reduction in barbiturate induction dose.40-50%IV anesthetic agent chosen for induction in elderly patients with CV instability.EtomidateEtomidates initial Vd is decreased in the elderly and requires a reduction of _____%50%IV anesthetic superior for recovery of mental function in elderly but may give rise to exaggerated decreases in BP with induction. It is highly lipid soluble and produces rapid loss of consciousness.PropofolDue to geriatrics large _____ elimination is prolonged with benzodiazepines and there is an enhanced pharmacodynamic sensitivity. Requirements are ___% less in elderly.Vd 50%Geriatric patients have an enhanced pharmacodynamic sensitivity to opioids but ______ is not altered. Requirements are ____% less.Pharmacokinetics (what the body does to the drug) 50%Of the neuromuscular blockers, geriatric response to _____ is unaltered.Succinylcholine slightly prolonged in the elderly male due to decreased cholinesteraseOnset of muscle relaxants in the elderly is PROLONGED/SHORTENED/UNCHANGED.prolonged due to decreased cardiac output & slow muscle blood flowRecovery from muscle relaxants in the elderly is dependent on _____excretion/eliminationThe muscle relaxant, _______, is prolonged in renal impairment.Pancuronium2 muscle relaxants that are prolonged in hepatic impairment.Vecuronium and RocuroniumWhich 3 muscle relaxants are eliminated through Hoffman's elimination?1. Cistracurium 2. Atracurium 3. MivacuriumWhat 2 things determine Hoffman's elimination?pH and temperatureIn the elderly you get "more bang for the buck". You should reduce your dose by ____to____% for most drugs. Remember to titrate slowly and be patient for the expected response.25-50% YOU CAN ALWAYS GIVE MORE, BUT YOU CAN'T TAKE IT BACK!Epidural anesthesia for the geriatric patient requires SMALLER/LARGER doses. Why?Smaller narrowing of intervertebral spaces causes a more cephalad spread of LAEpidural anesthesia for the geriatric patient results in a SHORTER/LONGER motor blockade/analgesia.Shorter narrowing of intervertebral spaces causes a more cephalad spread of LASpinal anesthesia for geriatric patients results in a SHORTER/LONGER duration. Why?prolonged duration Decreased blood flow to the subarachnoid space=slower absorptionSpinal anesthesia for geriatric patients results in FASTER/SLOWER onset. Why?Faster smaller volume of CSF with increased specific gravity=increases final concentration of given dose=faster onset/higher levels/ prolonged durationWith spinal anesthesia, geriatric patients have a(n) INCREASED/DECREASED incidence of post-dural puncture headache.decreasedMost common postop complication in elderly. (5-50% of elderly population)Postoperative Cognitive Dysfunction (POCD)Postoperative Cognitive Dysfunction manifests as a spectrum of neurologic derangements including?Mild/transient postop delirium to permanent cognitive declineRisk factors for Postoperative Cognitive Dysfunction include what 6 things?1. Preoperative cognitive impairment/dementia 2. Old age 3. Poor physical function 4. High risk surgical operation (hip fx, major vascular) 5. Untreated pain 6. InfectionBoth anesthetic and nonanesthetic factors are likely responsible for Postoperative Cognitive Dysfunction (POCD), although causes remain unclear. Incidence appears to be similar with both regional and general anesthetic techniques. Some possible causes include? (7)Drug effects Pain Underlying dementia Hypothermia Metabolic disturbances Central-acting anticholinergics (Atropine/Scopolamine) Low levels of certain neurotransmittersThe Genitourinary system consists of what 6 parts?1. Kidney 2. Ureter 3. Bladder 4. Prostate 5. External Genitalia 6. UrethraSensory supply of the GU system is mostly the ______ and _______ making many of the procedures well suited for regional anesthesia.thoracolumbar (SNS) sacral outflowKidney Sympathetic innervationT8-L1Kidney PSNS innervationCN X (Vagus)Ureter SNS innervationT10-L2Ureter PSNS innervationS2-S4Bladder SNS innervationT11-L2Bladder PSNS innervationS2-S4Prostate SNS innervationT11-L2Prostate PSNS innervationS2-S4Penis SNS innervationL1, L2Penis PSNS innervationS2-S4The kidneys are located in the _______ space with there centers at the _____ intervertebral body.retroperitoneal L2The kidneys are sympathetically innervated at ____ preganglionic fibers and parasympathetically innervated by the _____.T8-L1 Vagus nerveUreters represent the tubular extension of the renal collecting system connecting the _____ to the _____.kidneys to the bladderThe ureter is generally ____ cm in length22-30cmThe ureters are sympathetically innervated by _____ and parasympathetically innervated by _____.T10-L2 S2-S4The bladder and urethra are located in the _____ space.retropubicThe bladder and urethra are sympathetically innervated by T11-L2 which conducts ____, ____, & ____.pain, temperature, & touchThe bladder and urethra are parasympathetically innervated by S2-S4 which is the main ____ supply of the bladder and provides the sensation of _____ & _____ of the bladder.motor stretch & fullnessThe prostate is sympathetically innervated by _____ and parasympathetically innervated by _____. Spinal levels of pain conduction are the same.T11-L2 S2-S4The penis is sympathetically innervated by L1 & L2 with ANS supply to the _____ tissue.urethra/cavernousThe penis is parasympathetically innervated by S2-S4 that supplies ____ sensation.(pudendal) pain sensationAlong with the penis, the _____ is also has SNS (L1 &L2) and PSNS (S2-S4) innervation (cutaneous).ScrotumThe testes descend from an intra-abdominal location during fetal development and share embryologic origin with the _____ & _____.Kidney & UreterThe testes sympathetic nerve supply extends up to ____ & through ____.T10 through L1The testes are parasympathetically innervated via the _____.vagus nerveThe spinal levels of pain conduction for the kidney are _____.T6-L1The spinal levels of pain conduction for the ureter are _____.T10-L2The spinal levels of pain conduction for the prostate are _____ & _____.T11-L2 & S2-S4The spinal levels of pain conduction for the bladder are _____ & ____.T1-L2 (dome) & S2-S4The spinal levels of pain conduction for the urethra are _____.S2-S4The spinal levels of pain conduction for the testes/ovaries are ______.T10-L1The spinal levels of pain conduction for the external genitalia are _____.S2-S4The patient population we usually see in the OR consists of what 4 things?1. Advanced Age 2. Cardiac disease 3. Respiratory disease 4. Renal disease Evaluate coexisting diseases that might influence anesthetic management & monitoring anestheticEndourology consists of what 7 procedures?1. Cystourethroscopy 2. Ureteroscopy 3. Stent placement 4. Distal stone manipulation/laser lithotripsy 5. Transurethral resection of the prostate (TURP) 6. Transurethral resection of the Bladder (TURB) 7. Percutaneous nephrostomy/nephrolithotomy7 Common GU procedures include?1. Varicocelectomy 2. Orchiectomy 3. Bladder suspension 4. Penile implant 5. Prostatectomy 6. Nephrectomy 7. Cystectomy_____ are large, twisted veins that drain blood from the testicles. They are much like varicose veins of the leg. Most often, they occur after puberty on the left side of the scrotum. Once it is present, it will not go away on its own.VaricocelesSimple procedure done in testicular cancer for a retroperitoneal lymph node dissection.Orchiectomy4 approaches to doing a prostatectomy1. Radical retropubic 2. Perineal 3. Laparoscopic 4. Robotic2 approaches to doing a nephrectomy1. Laparoscopic/hand-assisted 2. OpenCystourethroscopy & Ureteral procedures are used to examine/treat lower _____ disease.urinary tract (bladder/lower third ureters)Indications for cystourethroscopy & Ureteral procedures include what 7 things?1. Hematuria 2. Recurring UTI 3. Urinary obstruction 4. Bladder biopsies 5. Resection of Bladder tumors 6. Extraction of stones 7. Placement of urethral stents The anesthetic technique depends on the age, gender, and surgical procedureWhat anesthetic technique is preferred for cystourethroscopy & ureteral procedures in children?General AnesthesiaWhat anesthetic technique is preferred for cystourethroscopy & ureteral procedures in Females during short diagnostic cases?Topical for short diagnostics (shorter urethras)What anesthetic technique is preferred for cystourethroscopy & ureteral procedures in Females during longer more extensive operative cases?General or Regional for longer more extensive (operative) proceduresWhat anesthetic technique is preferred for cystourethroscopy & ureteral procedures in Males?General or Regional (longer urethra)What anesthetic technique is preferred for cystourethroscopy & ureteral procedures for apprehensive patients?ALL SQUIRRELS GO TO SLEEP!What anesthetic technique is suitable for outpatient surgery for cystourethroscopy & ureteral procedures?Any anesthetic technique -General preferred for shorter OP procedures -LMA popular -GETA controlled ventilation >obese in lithotomy/T-burg positionRegional anesthesia can be used for urethral procedures with a _____ blocksacral (S2-S4)Regional anesthesia can be used for bladder procedures with a ____ block.T10 levelRegional anesthesia can be used for Ureteral procedures with a ____ block.T8-T10What position is common in cystourethroscopy & ureteral procedures and what 6 concerns are related?Lithotomy position 1. Associated with major physiologic alterations 2. Decreased FRC 3. Increased BP or fluid overload in CHF 4. Lowering legs rapidly decreases BP 5. Nerve injuries 6. Acute compartment syndrome of the extremitiesParoxysm of generalized sympathetic hyperactivity in response to stimulation below the level of the cord lesionAutonomic HyperreflexiaSpinal cord injury at which level puts the patient at increased risk for Autonomic Hyperreflexia?Above T6Symptoms of Autonomic Hyperreflexia related to vasoconstriction and vasodilation?1. Severe HTN & bradycardia (vasoconstriction below the cord) 2. Flushing/nasal congestion (vasodilation above the cord)Autonomic Hyperreflexia is inhibition of normal descending inhibitory impulses in the spinal cord. Sympathetic discharge below the lesion reacts to ______ stimulus unopposednoxious______ is very effective in preventing autonomic hyperreflexia, however, exaggerated hypotension, difficult placement, and determination of level limits it's use!Spinal anesthesiaIn autonomic hyperreflexia stimulus below the level of the injury (i.e. extended bowel or bladder) causes afferent stimulus of the spinal cord which results in a massive _____ response causing widespread _____ & _____.sympathetic vasoconstriction & hypertensionThe vasoconstriction & hypertension secondary to sympathetic response during autonomic hyperreflexia is detected by the _____ in the blood vessels as hypertensive crisis and signals the brain through cranial nerves ____ & ____.baroreceptors IX & XThe signals from the baroreceptors of hypertensive crisis to the brain during autonomic hyperreflexia causes ____ through cranial nerve X. Descending inhibitory signals are blocked at the spinal cord injury.decreased HRBladder perforation from cystourethroscopy & ureteral procedures is caused by ______ or ______.resectoscope or over distention of the bladder (by poor return of irrigating solution)3 S &S of a small extraperitoneal leak from bladder perforation during a cystourethroscopy or Ureteral procedure1. Nausea 2. Diaphoresis 3. Retropubic/pelvic/lower abdominal painA Large extraperitoneal or intraperitoneal leak from the bladder causes SUDDEN ______ & ______.Hypo- or hypertension & BradycardiaDiagnosis of bladder perforation is difficult in Spinal anesthesia because?Abdominal pain is not evident until level recedesDiagnosis of bladder perforation is difficult in General anesthesia and includes what 2 signs and symptoms?1. Increased PIP (mechanical ventilation) 2. Difficulty breathing (spontaneous ventilation)The obturator reflex is stimulated through the ______.bladder wallWhat position can stimulate the obturator reflex?External rotation & adduction of the thighObturator reflex stimulation is most common with what procedure?TURBThe obturator reflex is only reliably blocked by _____.muscle relaxants -general anesthesia with muscle relaxation requiredIndication for a transurethral resection of the prostate (TURP)?Benign Prostatic Hypertrophy (BPH) with gland volumes < 40-50mls with LUTS (lower urinary tract symptoms)Lower urinary tract symptoms (LUTS) related to BPH include what 5 signs & symptoms?1. Persistent gross hematuria 2. Recurring UTI 3. Renal insufficiency 4. Bladder stones 5. Renal failureProstate glands > ____ mls require and alternate approach to TURP (Radical Prostatectomy)>80 mlsBPH nonresponsive to ________ are treated with TURP.5-alpha reductase inhibitors (Proscar, Avodart)TURP is used in advanced prostatic carcinoma to relieve ______.symptomatic urinary obstructionThe surgical technique for TURP is resection of prostate tissue using a high frequency cutting current applied to a loop. ______ occurs by sealing vessels with coagulation current.Hemostasis_______ is used during a TURP to allow for improved visibility and flushing of resected tissue and blood.Continuous irrigationMajor complications related to TURP include what 6 things?1. TURP syndrome 2. Bladder perforation 3. Hemorrhage 4. Hypothermia 5. Septicemia 6. DIC complications due to vascularity of prostate and absorption of irrigating solutionThe prostate gland consists of an extensive network of _____ that are opened during resection of the prostate tissue resulting in systemic absorption of irrigation solution during a TURP.venous sinusesTURP Syndrome develops with an absorption of > ____ L of irrigating solution.> 2 Liters4 manifestations of TURP syndrome1. Circulatory volume overload 2. Dilutional hyponatremia 3. Hypo-osmolality 4. Toxicity from solute in irrigation solutionDeterminants of volume of irrigating solution absorbed during a TURP include what 4 things?1. Duration of resection 2. Height (hydrostatic pressure) of the irrigation fluid 3. Number & size of venous sinuses opened 4. Venous pressure____ ml/min of irrigation solution is absorbed during a TURP. The resection should be limited to ____ minutes.20ml/min 45-60 min (900-1200ml)The irrigation solution bag during a TURP should be no higher than ____ cm above the OR table. AVOID over distention of the bladder and drain frequently.60cmLarger prostate glands (>____ g) are at higher risk for TURP syndrome.>50 gThe lower the venous pressure during TURP the MORE/LESS irrigant fluid absorbed.More (those with hypovolemia/hypotension)The ideal irrigating solution for TURP has what 8 properties?1. Isotonic 2. Nonhemolytic 3. Nontoxic 4. Not metabolized 5. Rapidly excreted 6. Non electrolytic to disperse electrical current 7. Transparent to allow clear visibility 8. Inexpensive -several solutions have been evaluated, but all have limitationsThe original solution used for TURPs. It was nonconductive with excellent visibility, hypo-osmotic (0 mOsm/L), but had significant absorption causing dilutional hyponatremia, hemolysis, & hemoglobinemia/hemoglobinuria. It has all but been abandoned for TURPs because of the development of nearly isotonic, nonelectrolyte containing solutions.Distilled Water ECF hypo-osmolality will result in movement of fluid from ECF to ICF =cell volume will swell...BURST/Hemolysis Moderate hypotonicity maintained for visual qualitiesAlthough distilled water has been abandoned for TURPs it is still used only for _____ & _____.cystoscopy & TURBThis irrigating solution disperses electrical current from the resectoscope, is uncomfortable for the patient, dangerous for the patient & surgeon, and can not be used during TURP.Electrolyte solutions (NS/LR)The electrolyte solution (NaCL) is used for continuous irrigation of the bladder after completion of TURP to prevent ______ and reduce the risk of postoperative _______ due to the continued absorption of the irrigating solution.clots hyponatremiaThis irrigating solution used for TURP is hypo-osmotic (200-230 mOsm/L) making it less likely to cause TURP syndrome. It is non-electrolytic and is popular but not used the most due to risk of hyperglycinemia.Glycine (1.5%) Glycine is an inhibitory neurotransmitterHyperglycinemia related to Glycine (1.5%) irrigating solution during TURP causes what 3 things?1. Circulatory depression 2. CNS toxicity 3. Visual disturbances -Blurred Vision -Transient blindnessGlycine metabolism/degradation results in _______ which causes CNS toxicity.hyperammonemiaHypo-osmotic (165 mOsm/L) TURP irrigating solution that is rapidly metabolized into 70% CO2 & 30% dextrose causing hyperglycemia and lactic acidosis.Sorbitol (3.3%)Isosmolar solution (275 mOsm/L) used during TURP that is not metabolized but results in osmotic diuresis.Mannitol 5%The osmotic diuresis related to the TURP solution Mannitol 5% can cause what 2 problems?1. Acute intravascular volume expansion 2. Cardiac decompensation (CHF/PE)Hypo-osmotic (195 mOsm/L) TURP solution that consists of 2.7% sorbitol & 0.54% mannitolCytalThe TURP solution most commonly used is _____.Sorbitol (3.3%) - Mannitol 5% and Cytal are among the better choices, as well.An osmotic diuresis is induced when an agent is administered that is freely filtered into Bowman's capsule and remains trapped in the renal tubule (i.e., the substance very poorly permeates the tubule wall). The impermeable substance exerts an osmotic force and hinders the reabsorption of water. ______is a substance that is capable of producing an osmotic diuresis.Mannitol Even though mannitol is slightly hypo osmotic, it has enough solute to prevent significant movement of fluid from ECF to ICF that results in hemolysisEarly clinical manifestations of TURP Syndrome (5)Acute intravascular volume expansion 1. HTN 2. Bradycardia (baroreceptor mediated) 3. Cardiac decompensation/CHF 4. Pulmonary Edema 5. Cardiovascular collapseLater clinical manifestations of TURP Syndrome (2)1. Dilutional hyponatremia 2. Cerebral Edema______ is responsible for most of the signs and symptoms of TURP syndrome.Rapid changes in sodium, as opposed to a specific low threshold serum sodium concentrationSigns and symptoms of Acute hyponatremia of 120 mEq/L includes what CNS and what ECG changes?CNS: Confusion & Restlessness ECG: Possible widening of QRS complexSigns and symptoms of Acute hyponatremia of 115 causes what CNS changes and what ECG changes?CNS: Somnolence & Nausea/Vomiting ECG: Widened QRS & Elevated ST segmentSigns and symptoms of Acute hyponatremia of 110 causes what CNS changes and what ECG changes?CNS: Seizure & Coma ECG: V-tach & V-fibSigns and symptoms of Acute hyponatremia of <100 causes what CNS changes?CNS: Intravascular hemolysisClassic triad related to TURP Syndrome in awake patient with regional anesthesia1. Increase in both SBP & DBP associated with increased pulse pressure (volume overload) 2. Bradycardia 3. Mental status change -Restlessness -Nausea/Vomiting -Mental confusion -Visual disturbances_______is the difference between the systolic and diastolic pressures.Pulse pressureNormal range for pulse pressure should be ______mmHg, with _____ the average.30-50 mmHg 40 mmHgA decreased pulse pressure (less than 30 mmHg) is related to factors that cause __________.1. an increase in the diastolic blood pressure 2. a decrease in systolic blood pressure 3. or a combination of bothCauses of decreased pulse pressure include what 4 things?1. peripheral vasoconstriction 2. aortic valve stenosis 3. mitral valve insufficiency 4. decreased stroke volume due to heart failure or hypovolemia.An increased pulse pressure (greater than 50 mmHg) is related to factors that cause a _______.1. decrease in the diastolic blood pressure 2. an increase in systolic blood pressure 3. or both.Causes of increased pulse pressure include what 5 things?1. hypertension 2. circulatory overload 3. arrhythmias 4. increased stroke volume caused by anxiety or exercise 5. decreased distensibility of the arteries as seen in arteriosclerosis and aging.Early recognition of TURP Syndrome is vital! Treatment includes what 4 things?1. Notify surgeon to terminate the procedure ASAP 2. Ensure oxygenation and circulatory support -AVOID hypoxemia/hypoperfusion 3. Send blood to the lab for serum sodiumTreatment of TURP syndrome with mild symptoms with a serum sodium level of > 120 meq/L includes what 2 interventions?1. Fluid restriction 2. Loop diuretic (furosemide)Treatment of symptomatic TURP syndrome with serum sodium < 120 mEq/L includes what intervention?Hypertonic saline (3-5%) at a rate of 100ml/hr Discontinue when sodium level is > 120 mEq/LWhat are 2 concerns related to Hypertonic Saline administration for treatment of symptomatic hyponatremia related to TURP syndrome?1. Exacerbation of fluid overload 2. Central pontine myelinolysis -Rapid correction/increase in plasma osmolality has been associated with CNS lesions (central pontine myelinolysis) due to excess shrinkage of brain cells after rapid hydration with hyperosmotic solution.Seizure treatment related to hyponatremia secondary to TURP Syndrome is treated with what 4 interventions?1. Benzodiazepine (Valium/Versed) 2. STP (50-100mg) 3. Phenytoin (10-20mg/kg, no faster than 50 mg/min) 4. Intubate to prevent aspirationWhat is the dosage of STP for seizure treatment related to hyponatremia secondary to TURP Syndrome?50-100mgWhat is the dosage of Phenytoin for seizure treatment related to hyponatremia secondary to TURP Syndrome and at what rate should you not infuse Phenytoin no faster than?10-20mg/kg no faster than 50mg/minSepticemia/septic shock related to TURP results from?bacteria from the prostate together with the opening of the venous sinusesProphylaxis antibiotics used to prevent Septicemia/septic shock in TURP include what 3?Gentamicin Levofloxacin CiprofloxacinHypothermia related to TURP is a result of ______.Room temperature irrigation fluids (not warmed) Does not develop if solution is warmed to body temperatureDuring TURP, room temperature fluids cause a decrease in temperature by _____ degrees Celsius per hour of surgery.1 degree CelsiusShivering during TURP procedure due to hypothermia can cause what complication?Dislodge of clots and postoperative bleedingBleeding/hemorrhage in TURP is related to the open venous sinuses. It is difficult to quantify due to mixing with irrigating fluid. An estimation of _____ ml/min of resection.2-4 ml/minTransfusions related to bleeding during TURP should be guided by _____ & ______serial HCT & patient vital signsAbnormal bleeding related to TURP is due to a release of ______ or _____from the prostate into circulation and can result in _____ & ______.thromboplastin or TPA DIC (secondary to fibrinolysis) & Primary fibrinolysisPrimary fibrinolysis secondary to release of TPA from the prostate during TURP and can be treated with ______.AmicarDIC is related to a release of thromboplastin from the prostate into circulation during TURP and treatment requires _________.guidance from the hematologist to treatAbnormal bleeding in TURP related to thrombocytopenia is suspected with _____ and confirmed with ______.diffuse, uncontrolled bleeding lab valuesTissue plasminogen activator (catalyzes conversion plasminogen to plasmin which breaks down blood clots)TPAAids in conversion of prothrombin to thrombin to form clot. Too much=hypercoagulable= fibrinolysis=hypocoagulableThromboplastinDuring a TURP procedure you obtain a set of labs that include ↓PLT, Na+, HCT with ↑ CVP. What do you suspect and how would you treat this patient?Dilutional:treat with diuresisDuring a TURP procedure you obtain a set of labs that include ↓PLT, Normal Na+, ↓HCT, Normal/low CVPExcess blood loss: transfuse platelets/PRBCWhat population are getting TURPs and what coexistent diseases are associated with this population?Elderly -Cardiac disease (67%) - CV (50%) -COPD (29%) -DM (8%)A type and screen is sufficient for most TURP patients, however, a type and cross is needed for what 2 things?1. Anemia 2. Large glands (>40g) Keep in mind that transfusion rate for TURP is about 6%You are awaiting a BMP on a patient scheduled for TURP. The procedure should be postponed if the sodium level results less than what value?< 128 mEq/LWhat antibiotic and dosage is used for prophylaxis in TURP?120-240 mg Gentamicin_____ Anesthesia is preferred during TURP if possible due to early diagnosis of TURP Syndrome/bladder perforation & decreased thromboembolic events.Regional -Spinal is preferred over epidural due to faster onset and quicker recoveryWhat dermatome level is required for regional anesthesia for TURP to block pain from bladder distention?T10TURP surgery is performed in lithotomy position causing a decrease in _____, predisposing patients to atelectasis and hypoxia. Rapid lowering of the legs at the end of the operation acutely _______and can result in severe hypotension, especially when combined with blood loss during surgeryFRC decreases venous returnClinical studies fail to show difference in blood loss, postop cognitive function, and mortality between GA and Regional. Both are safe and choice is tailored to individual need. Very obese or mentally handicapped (communication difficult) patients ________ may be a better option.General anesthesia (ETT or LMA)Urinary tract calculi or stones.UrolithiasisUrolithiasis is 3 times more common in _____.MenPeak age for Urolithiasis is _____3rd or 4th decade (30-40 years old)The annual incidence for urolithiasis is 16.4 per 10,000 persons and an estimated 12% will experience calculus disease. Treatment is dependent on what 3 things?1. Size of the stone 2. Location in the urinary tract 3. Composition4 Indications for percutaneous nephrostomy/nephrolithotomy1. Relief of renal obstruction 2. Stone removal from kidney or upper 2/3 of the ureter 3. Biopsy of tumor 4. Ureteral stent placementPercutaneous nephrostomy/nephrolithotomy is done under _____ with the catheter/sheath inserted _____.fluoroscopy directly into the kidney (access and drainage to kidney)Patient position for percutaneous nephrostomy/nephrolithotomyProne or Flank positionWhat anesthetic plan is appropriate for nephrostomy?Local or MAC or GeneralWhat anesthetic plan is appropriate for nephrolithotomy?General or RegionalPotential complications related to percutaneous nephrostomy/nephrolithotomy include what 3 things?1.Trauma to the spleen, liver, or kidney 2. Pleural injury 3. Continuous irrigation extravasation into retroperitoneal, intraperitoneal, intravascular, or pleural spaces (similar to TURP Syndrome).Trauma to the spleen, liver, or kidney during percutaneous nephrostomy/nephrolithotomy causes acute blood loss requiring an ______emergency open procedurePleural injury during percutaneous nephrostomy/nephrolithotomy can result in pneumothorax, hydropneumothorax, hemothorax, or pleural effusion due to access above the ____ rib.12thWhat continuous solution is used during percutaneous nephrostomy/nephrolithotomy?NaCl used since cautery rarely usedNoninvasive technique that dramatically changed the management of urolithiasis. Most common technique was open surgical removal but now only 5% require open.Extracorporeal Shock Wave Lithotripsy (ESWL)Extracorporeal Shock Wave Lithotripsy (ESWL) uses repetitive high-energy shocks focused on the stone that results in pulverization of renal stones. It can be used for disintegration of calculi in the kidney or upper portion of the ureter. What are 2 advantages of this technique?1. Minimally invasive 2. Minimal perioperative morbidity1st generation Extracorporeal Shock Wave Lithotripsy (ESWL) that is no longer common requiring water immersion.ElectrohydraulicThe impact of shock wave during Electrohydraulic Extracorporeal Shock Wave Lithotripsy (ESWL) is painful requiring _____ or _____ anesthesia.General or RegionalEffects of immersion with Electrohydraulic Extracorporeal Shock Wave Lithotripsy (ESWL) include what 3 things?1. Hydrostatic pressure on legs/abdomen 2. Vasodilation/venous pooling from warm water 3. Increase in intrathoracic blood volume & chest pressureHydrostatic pressure on the legs and abdomen during Electrohydraulic Extracorporeal Shock Wave Lithotripsy (ESWL) causes venous compression resulting in ______. This results in a(n) INCREASE/DECREASE in SVR and a(n) INCREASE/DECREASE in CO.increased blood volume Increased SVR Decreased CO -exacerbates CHF in those with marginal cardiac reserveVasodilation/venous pooling from warm water during Electrohydraulic Extracorporeal Shock Wave Lithotripsy (ESWL) causes ______.transient hypotension -had to slowly remove from the tub to prevent profound hypotension at completionIncreased intrathoracic blood volume and chest pressure from Electrohydraulic Extracorporeal Shock Wave Lithotripsy (ESWL) causes a decrease in what 3 lung volumes?1. FRC 2. VC 3. Vt Effects of immersion are directly related to depth of immersion. Achieve immersion in a gradual fashion or perform with minimal immersion so only shock wave entry site is covered with water.2nd generation Extracorporeal Shock Wave Lithotripsy (ESWL) that involves the patient be placed on a lithotripsy table and shock wave generation through an enclosed water-filled gel pad that is directed at the area of the stone.ElectromagneticElectromagnetic Extracorporeal Shock Wave Lithotripsy (ESWL) require lower shock waves reducing pain significantly. What anesthesia technique is appropriate?MAC or Light Anesthesia (however, breathing plays an important role in stone/lithotripsy alignment )During Extracorporeal Shock Wave Lithotripsy (ESWL), asynchronization of shock wave delivery to ECG can cause ______ if the shock wave is delivered during a non-refractory or relative refractory period (depolarization)R-on-T wave phenomenonDuring Extracorporeal Shock Wave Lithotripsy (ESWL), shock waves are timed ___ milliseconds after R wave to correspond to ____ refractory period.20 milliseconds absolute (decreased arrhythmias)The length of Extracorporeal Shock Wave Lithotripsy (ESWL) is _____ dependent. What 2 medications can be given to shorten the procedure?heart rate Atropine or GlycopyrrolateExtracorporeal Shock Wave Lithotripsy (ESWL) asynchronized delivery of shock waves can be safely used in patients without _____heart diseaseIn case of lethal arrhythmia during Extracorporeal Shock Wave Lithotripsy (ESWL) what should be your first action?Hit the kill switch on the machineThe period of depolarization and repolarization of the cell membrane after excitation.refractory period -during the first portion (absolute refractory p.), the nerve or muscle fiber cannot respond to a second stimulus, whereas during the relative refractory period, it can respond only to a strong stimulusThe time when a stimuli can depolarize myocardial tissue.Non-refractory PeriodThe time when myocardium is unresponsive to any stimuliAbsolute refractory PeriodThe time when a stimuli might induce a depolarization.Relative Refractory Period3 Contraindications to Extracorporeal Shock Wave Lithotripsy (ESWL)1. Bleeding disorder 2. Anticoagulation 3. Pregnancy5 Absolute Contraindications to Extracorporeal Shock Wave Lithotripsy (ESWL)1. Large calcified aortic or renal artery aneurysm 2. Untreated UTI 3. Obstruction distal to renal calculi 4. Pacemaker/AICD/neurostimulation implant 5. Morbid obesityDuring Extracorporeal Shock Wave Lithotripsy (ESWL) General Anesthesia allows control of ______.diaphragmatic movement -diaphragmatic movement with spontaneous ventilation can move stone in/out of the wave focus prolonging the procedureDuring General Anesthesia for Extracorporeal Shock Wave Lithotripsy (ESWL) you want a ____ RR and _____ Tidal volumesslow RR small VtAnesthetic plan preferred with Immersion Extracorporeal Shock Wave Lithotripsy (ESWL).Continuous Epidural_____ sensory level required with continuous epidural during Immersion Extracorporeal Shock Wave Lithotripsy (ESWL).T6Anesthetic plan for low-energy Extracorporeal Shock Wave Lithotripsy (ESWL).MAC or "light" GeneralWhat 2 things should be monitored during Extracorporeal Shock Wave Lithotripsy (ESWL)1. EKG for ventricular dysrhythmias 2. Temperature (Hyper or hypothermia)During Extracorporeal Shock Wave Lithotripsy (ESWL) ____ + _____ maintains brisk urinary flow/flushes out stones/blood.generous IVF therapy + small dose furosemideIn patients with pacemakers what 4 measures should be met before undergoing Extracorporeal Shock Wave Lithotripsy (ESWL)?1. Preop determination of type/function 2. Availability of programming device in OR 3. Availability of alternate pacing device 4. Position patient so pacemaker is NOT in shock wave pathIn patients with AICDs what measure should be taken prior to Extracorporeal Shock Wave Lithotripsy (ESWL)?Deactivate the defibrillator during lithotripsy4 Radical Urological Procedures for Malignancies1. Prostatectomy -radical retropubic -perineal -laparoscopic/robtic 2. Cystectomy -with or without urinary diversion 3. Orchiectomy -with or without retroperitoneal lymph node dissection 4. NephrectomyThe most common cancer in MenProstate Cancer____ remains the Best therapeutic intervention for prostate cancer in men < 65 years old.Radical ProstatectomyRadical Prostatectomy includes removal of what 4 things?1. prostate 2. bladder neck 3. seminal vesicles 4. ampullae of the vas deferens -lymph node dissection at timesTraditional approach to prostate removal that requires a transverse abdominal incision.Open Radical Retropubic ProstatectomyBlood loss for an Open Radical Retropubic ProstatectomySignificant > 1000 mlAnesthetic management for an Open Radical Retropubic Prostatectomy includes what 4 interventions?1. Intravascular fluid volume management 2. Maintain normothermia 3. Careful positioning 4. Employ techniques to limit blood lossMonitoring of an Open Radical Retropubic Prostatectomy is dictated by ______ & ______.Comorbidities & anticipated blood lossAn A-line may be warranted during an Open Radical Retropubic Prostatectomy for ____ & ____.continuous BP monitoring & serial Hgb (invasive monitoring unnecessary if surgeon good & patient healthy)A CVP may be used during an Open Radical Retropubic Prostatectomy to assess and guide ______ and provide access for ______.fluid management (urine flow is interrupted) rapid transfusion (invasive monitoring unnecessary if surgeon good & patient healthy)How many large bore IVs are necessary for an Open Radical Retropubic Prostatectomy ?2 for rapid transfusion (also may need a fluid warmer)How many units of PRBC should be type and crossed for an Open Radical Retropubic Prostatectomy ?4 unitsWhat patient position is common for an Open Radical Retropubic Prostatectomy and what are the complications/risks associate?Hyperextended supine position with T-burg 1.VAE 2. Venous pooling head/neck -airway patency issues -difficult tracheal extubation especially with significant blood loss and fluid resuscitation 3. Back/nerve injuryWhat NSAID can be administered for an Open Radical Retropubic Prostatectomy that decreases opioid requirements, improves analgesia, and is associated with earlier return of bowel function without increasing transfusion requirements?Ketoralac (Always ask surgeon before administering Toradol)What are pros and cons of use of Regional Anesthesia during an Open Radical Retropubic Prostatectomy ?Pros: 1. Decreased incidence of postoperative DVT's - Effect is negated by prophylaxis use of LMW Heparin in the postop period Cons: 1. Long procedure 2. Prolonged T-burg -upper airway edema with significant fluid resuscitation 3. Overall, not tolerated well by most patients_____ is typically indicated or preferred in an Open Radical Retropubic Prostatectomy .GETATry to AVOID _____ during Open Radical Retropubic Prostatectomy due to immunologic & infection complications, impaired immune response which may predispose to cancer recurrence, and expensive.blood transfusionHow are blood transfusions avoided during Open Radical Retropubic Prostatectomy ?1. Acute normovolemic hemodilution 2. Autologous blood 3. Cell saver -controversial due to risk of tumor seedingWhat are 5 Advantages of Perineal Prostatectomy?1. Shorter operative time 2. Better margin positive & biochemical recurrence rate 3. Decreased blood loss & need for transfusion 4. Reduced postop pain 5. Shorter recovery timeWhat are 3 Disadvantages of Perineal Prostatectomy?1. Exaggerated lithotomy position 2. Nerve/muscle injury 3. Difficult ventilationMonitoring for Perineal Prostatectomy, although blood loss less, need for CVP or A-line guided by ______.patient comorbiditiesAnesthetic technique most often indicated for Perineal ProstatectomyGeneralAlthough the surgical site is amenable to regional during Perineal Prostatectomy, Regional Anesthesia is poorly tolerated by the patient due to _____ and profound alterations in _____.position ventilationWhat are 5 Advantages to Laparoscopic Radical Prostatectomy?1. Shortened recovery with more rapid return to normal activity 2. Shorter urinary catheter duration 3. Patient satisfaction 4. Better quality of life 5. Decreased blood lossWhat 2 things decrease blood loss during Laparoscopic Radical Prostatectomy?1. CO2 insufflation tamponades the prostatic venous bleeding 2. Magnification of the operative fieldWhat are 4 potential complications related to Laparoscopic Radical Prostatectomy?1. Standard concerns for laparoscopic surgery 2. Extended surgical time 3. Compromised ventilation -high abdominal insufflation pressure -STEEP trendelenburg position -PEEP beneficial 4. Greater CO2 absorption from the retroperitoneum (acidosis) -Carbon dioxide is readily absorbed from the peritoneum, causing an increase in PaCO2 and respiratory acidosis. This has marked effects on the cardiovascular system causing tachycardia and increased cardiac contractility. Diffusion of carbon dioxide into the body depends on the site of insufflation. Retroperitoneal insufflation of carbon dioxide is used for several urological procedures and may potentially cause carbon dioxide accumulation because the retroperitoneal space provides a greater potential for carbon dioxide absorption than the peritoneum. This is because the retroperitoneal space is very vascular, contains adipose tissue and is not as limited as the peritoneum. Carbon dioxide absorption may also persist after the end of surgeryWhat anesthetic technique is preferred for Laparoscopic Radical Prostatectomy and why?GETA 1. Length of surgery 2. Position 3. Abdominal distention 4. Control ventilation (acidosis)What anesthetic agent should be avoided in Laparoscopic Radical Prostatectomy and why?Nitrous Oxide bowel distentionAnesthetic considerations for Laparoscopic Radical Prostatectomy include1. Maintain normothermia -warm insufflation gases -forced air warmer 2. Facilitate faster emergence (fast-tracking) 3. IVF management -"VERY DRY" per surgeon request -Improves surgical fieldWhat 4 interventions should be implemented in Laparoscopic Radical Prostatectomy to allow for Fast-Tracking?1. Short acting anesthetic agents 2. Minimize opioid administration 3. Address PONV 4. Reduce insufflation pressures (<12mmHg)During Fast-tracking in Laparoscopic Radical Prostatectomy insufflation pressures should be reduced to < _____ mmHg to prevent problems related to venous return and ventilation.< 12mmHgAccounts for 10% of radical prostatectomies.Robotic Radical ProstatectomyThe Da Vinci robotic system consists of what 3 things?1. Surgeon console 2. Patient side cart 3. Image processing/insufflation cart2 Advantages of Robotic Radical Prostatectomy1. Significant decrease in blood loss (50-150 ml) 2. Significantly shorter hospital stay/convalescence1 Disadvantage of Robotic Radical ProstatectomyEXPENSIVEAnesthetic concerns with a Robotic Radical Prostatectomy include what 2 things?1. Similar to laparoscopic approach 2. Head-down low lithotomy position -Nerve injury -airway edema insufflation > 4 hours2nd most common urologic malignancyBladder Cancer -incidence increases with ageWhat is the gold standard of treatment for Bladder Cancer?Radical cystectomy with pelvic lymph node dissection -urinary diversion also possibleRadical Cystectomy has a fairly high complication/mortality rate with significant blood loss (____ml). Transfusion is common so ____ units of blood should be type and crossed and what baseline labs should be drawn?500-3000ml 4 units PT/PTT/INR & PLTWhat monitoring devices are indicated with Radical Cystectomy?1. 2 large bore IVs 2. A-line indicated 3. CVP advisable to guide IVF volume status -early interruption of urinary flow -significant insensible fluid loss (large midline incision) 4. PA catheter with advanced cardiac diseasePatients undergoing Radical Cystectomy are prone to hypothermia . What 2 devices may be needed to attenuate this?1. Fluid warmer 2. Forced air warmerWhat is the preferred technique for Radical Cystectomy and why?GETA 1. Long duration of surgery 2. Controlled hypotension -reduces blood loss -improves surgical visualizationCombined epidural with GETA facilitates induced hypotension, decreases general anesthetic requirements, and provides highly effective post op analgesia in Radical Cystectomy. What does it cause that makes this anesthetic technique undesirable?Hyperperistalsis -small contracted bowel complicates construction of a urinary reservoirUrinary diversion involves implantation of ureters into ________.a segment of the bowelAnesthetic considerations for urinary diversion includes what 2 things?1. Keep the patient well hydrated maintaining brisk urinary output and to prevent metabolic disturbances 2. Prevent/Alleviate a hyperactive, contracted bowelIf urine flow slows during urinary diversion what 3 things may result?1. Hyponatremia 2. Hypochloremia 3. HyperkalemiaIf urine flow slows during a urinary diversion with jejenual conduits what may result?Metabolic AcidosisIf urine flow slows during urinary diversion with colonic and ileal conduits what may result?Hyperchloremic metabolic acidosisWhat 4 interventions may be necessary to prevent/alleviate a hyperactive, contracted bowel?1. AVOID neuraxial anesthesia 2. Papaverine (100-150mg slow IV over 2-3 hours) 3. Glycopyrrolate (large dose of 1mg IV) 4. glucagon (1mg IV) most commonWhat is the initial treatment for testicular tumors?Radical OrchiectomyWhat subsequent treatments may be necessary if a testicular tumor is not contained?1. Retroperitoneal lymph node dissection 2. Chemotherapy (Bleomycin) 3. SurveillanceWhat patient population normally undergoes radical orchiectomy?typically young (15-35 years)A patient is scheduled for radical orchiectomy that has been on Cisplastin. What effect do you expect to find from taking this medication?Renal impairmentA patient is scheduled for radical orchiectomy that has been on bleomycin. What effect do you expect to see from taking this medication?Pulmonary fibrosis (restrictive pattern)A patient is scheduled for radical orchiectomy that has been on vincristine. What effect to you expect to see from taking this medication?NeuropathyIn Radical Retroperitoneal Lymph Node Dissection all lymphatic tissue between the ureters from the _______ to the ______ are removed.renal vessels to the iliac bifurcationIn the thoracoabdominal approach for Radical Retroperitoneal Lymph Node Dissection where does the incision start and end?Large thoracoabdominal incision from the posterior axillary line over 8th to 10th rib to paramedian line 1/2 way between xiphoid process and umbilicusIn the transabdominal approach for Radical Retroperitoneal Lymph Node Dissection the incision is midline from the _____ to ______.xiphoid to pubisWhat 2 complications result from the thoracoabdominal incision from a Radical Retroperitoneal Lymph Node Dissection?1. Nerve/back injury 2. VAEWhat anesthetic technique is preferred in Radical Retroperitoneal Lymph Node Dissection?GETA______ can result from traction of the spermatic cord during Radical Retroperitoneal Lymph Node DissectionReflex BradycardiaThere is risk for postoperative ______ with Radical Retroperitoneal Lymph Node Dissection due to the nature of the incisionpulmonary insufficiency/acute respiratory distress syndromePatient's who receive Bleomycin preoperatively to Radical Retroperitoneal Lymph Node Dissection are sensitive to ______ & ______.O2 toxicity & Fluid overloadTo prevent O2 toxicity & fluid overload related to preop use of bleomycin what 3 interventions are necessary?1. Use lowest inspired concentration of O2 to maintain SaO2 between 88-92% 2. Administer Air-O2 mix -Avoid prolonged N2O administration= bone marrow suppression 3. Administer PEEP (5-10cm)There is considerable ____ from Radical Retroperitoneal Lymph Node Dissection because of large wound and dissection.third spacingTo attenuate third spacing related to Radical Retroperitoneal Lymph Node Dissection fluid replacement should be guided by ______. Maintain UOP > ____ ml/kg/hr & combine the use of both ____ & ____ for fluid replacement.CVP readings > 0.5ml/kg/hr colloids and crystalloidsPrevention of surgically induced renal ischemia (AKI) during Radical Retroperitoneal Lymph Node Dissection can be attenuated by ____ to encourage UOP of 0.5mg/kg/hr.Mannitol (0.25 mg-0.5 g/kg)Transient hypotension during Radical Retroperitoneal Lymph Node Dissection results from ______.contraction of the inferior vena cava (cuts off venous return from lower 1/2 of the body)During Radical Nephrectomy what 4 things are removed?1. Kidney 2. Adrenal gland 3. Perinephric fat 4. surrounding fascia3 Surgical techniques for Radical Nephrectomy1. Open incision -Anterior subcostal -Flank -Midline -Thoracoabdominal 2. Laparoscopic 3. Laparoscopic Hand AssistedWhat patient position is used for a Radical Nephrectomy?Lateral flexed (kidney) position -maintain anatomical alignment and pad all pressure points -axillary roll -OR table extended to achieve max separation between iliac crest and costal margin -Kidney rest elevated to increase exposureIn the lateral flexed (kidney) position for radical nephrectomy the dependent leg is _____ and the nondependent leg is _____.dependent: flexed nondependent: extendedWhat effect does the lateral flexed (kidney) position during Radical nephrectomy have on FRC to the dependent and nondependent lung?Dependent : decreased FRC Nondependent: increased FRCWhat effect does the lateral flexed (kidney) position during Radical nephrectomy have on VQ mismatching/hypoxemia in the mechanically ventilated patient in the dependent and nondependent lungs?Dependent: decreased ventilation and increased blood flow Nondependent: increased ventilation and decreased blood flowWhat effect does the lateral flexed (kidney) position during Radical nephrectomy have on ETCO2-PaCO2 gradient?Increased dead space ventilation in the nondependent lung (ventilation without perfusion)What effect does the lateral flexed (kidney) position during Radical Nephrectomy have on circulation?1. Elevated kidney rest=decreased venous return=hypotension 2. Venous pooling in the legs=decreased venous return=exacerbates anesthesia induced vasodilationThere is potential for excessive blood loss in radical nephrectomy and hemodynamic instability due to blood loss and vena cava compression (retraction of inferior vena cava and positioning). What types of IVs and monitoring devices are indicated?1. 2 large bore IVs for rapid transfusion 2. Arterial line 3. CVP______ can be used during radical nephrectomy to reduce blood loss.Controlled hypotensionMaintain renal perfusion during radical nephrectomy in the non affected kidney with what 3 medications?1. Mannitol 2. Vasopressors (?) 3. Renal dose dopamine-controversialHow do the kidneys regulate ECF Composition/Volume? (4)1. Electrolyte Balance 2. Acid base balance 3. Serum osmolality 4. Excretes toxic substances and nonvolatile end-products of metabolismHow do the kidneys regulate hormones? (3)1. Erythropoietin 2. Renin-angiotensin-aldosterone system 3. Vitamin DThe functional unit of the kidneyNephronWhat 4 things does the Nephron regulate?1. Glomerular filtration 2. Tubular reabsorption (filtrate to the blood) 3. Tubular secretion (blood to the tubule) 4. Excretion (collecting duct to renal pelvis)What are 4 effects of anesthesia on renal function?1. Decreased renal blood flow 2. Decreased GFR 3. Decreased urinary flow 4. Decreased electrolyte excretionThe magnitude of the affect General and Regional Anesthesia have on renal function is proportional to the degree of _____ & ______ of sympathetic block & BP depressionDoes Regional or General Anesthesia have a greater affect on renal function due to sympathetic block?General indirect effects > direct effectsWhat are the INDIRECT cardiovascular effects of volatiles & IV anesthetics on renal function?Decreased CO + Decreased SVR= Decreased BP= Decreased RBF/PerfusionWhat are the INDIRECT cardiovascular effects of regional sympathetic blockade on renal function?Increased venous capacitance + Arterial vasodilation= Decreased BP= Decreased RBF/PerfusionWhat are the INDIRECT Neural effects of SNS over activity (endogenous/exogenous)on renal function?Increased catecholamines= renal vasoconstriction = increased renal vascular resistance(RVR) = Decreased RBF/GFR/urinary outflow Activates various hormone responsesWhat are the INDIRECT Endocrine (stress response) effects on renal function?1. Increased catecholamines 2. Increased renin released from kidneys (due to beta stimulation)= increased renal vascular resistance (RVR) & increased sodium reabsorption =decreased UOP 3. Increased Angiotensin II = increased RVR & decreased RBF 4. Increased ADH = Increased RVR & decreased RBF & increased H2O reabsorption in distal and collecting tubules= increased ECF 5. Increased Aldosterone = increased sodium reabsorption and favors H2O retention________ is responsible for increasing water absorption in the collecting ducts of the kidney nephron.Vasopressin (ADH)________stimulates water reabsorption by stimulating insertion of "water channels" or aquaporin's into the membranes of kidney tubules. These channels transport solute-free water through tubular cells and back into blood, leading to a decrease in plasma osmolarity and an increase osmolarity of urine. It also increases peripheral vascular resistance which in turn increases arterial blood pressureAntidiuretic hormoneVolatile agents are metabolized in the liver by ______ causing a release of ______ ions that DIRECTLY effect renal function because they are excreted via the kidney.oxidative defluorination fluoridePlasma fluoride concentrations > ____ umol/L DIRECTLY causes nephrotoxicity by causing a defect in the urinary concentrating ability leading to ________.> 50 umol/L Polyuric Renal FailureHigh-output Renal failure: polyuria (hypovolemia), proteinuria, glycosuria, impaired renal concentrating ability with a lack of response to vasopressin and an increased serum sodium, urea, creatinine and osmolarityPolyuric Renal FailureWhat 3 volatile agents DIRECTLY produce nephrotoxic levels of fluoride?1. Methoxyflurane 2. Sevoflurane 3. EnfluraneWhat 3 volatile agents undergo minimal biodegradation making fluoride production negligible (no risk to kidneys)1. Halothane 2. Isoflurane 3. DesfluranePlace the volatile agents in order from most nephrotoxic to least nephrotoxicMethoxyflurane > Sevoflurane > Enflurane > Isoflurane > DesfluraneWhat is Enflurane's chemical structure?Cl- on the 1st carbonWhat is Isoflurane's chemical structure?Cl- on the 2nd carbonWhat is Sevoflurane's chemical structure?7 fluorine'sWhat is Desflurane's chemical structure?6 fluorine'sWhat is Halothane's chemical structure?Not an ether No -O-Fluoride induced renal toxicity is mostly associated with _____ (1 MAC > 2hours)MethoxyfluraneFluoride induced renal toxicity can become significant with ______Enflurane_____ renal effects have been debated because numerous published reports indicate the absence of renal toxicity.Sevoflurane'sSevoflurane undergoes ____ % biodegradation raising concerns that it might result in renal toxicity similar to Methoxyflurane.2-5% concentrations exceeded 50umol/L after 2 MAC hoursSevoflurane metabolism readily releases inorganic fluoride with concentrations exceeding 50mmol/L after 2 MAC hours. However after extensive use for prolonged periods of time in Japan there have been no reports of renal dysfunction - Why?The peak fluoride level is short lived in sevoflurane anesthesia because the low blood/gas solubility coefficient allows rapid removal of the agent via the breath. The fluoride liberated during methoxyflurane anesthesia appeared to be produced in the kidney and was able to cause the damage directly. Sevoflurane is metabolized four times less readily in the kidney with lower fluoride levels within the kidney.CO2 absorbent degradation product of Sevoflurane that has the potential for nephrotoxicity.Compound A5Factors associated with generation of higher levels of Compound A with Sevoflurane1. Low FGF rates (<2L/min) 2. High concentration of agent 3. Fresh Baralyme 4. Increased temperature (>50 degrees C) in CO2 absorbent 5. Increased CO2 productionFresh gas flows must be maintained at a rate > ____ L/min with Sevoflurane to prevent high levels of compound A.>/= 2 L/minCompound A induced Sevoflurane undergoes spontaneous degradation, to compound A-E, when exposed to high temperatures (>50 C) that occur in Soda Lyme and Baralyme. Compound A has been found to be nephrotoxic but this is not usually an issue with Sodasorb - Why?The amount of compound A is dependent on the temperature of the absorber, Sodasorb is the most commercially used product and produces the lowest temperature 40 C because of the lack of KOH. The fresh gas flow used is very seldom minimal today and so helps wash out compound A Baralyme is worse than soda limeThe only proven DIRECT toxic effect of any anesthetic agent is the fluoride-related toxicity of ________.MethoxyfluraneNephrotoxic drugs include what 4 general classes?1. IV contrast dye 2. Antibiotics 3. NSAIDs 4. ImmunosuppressantsWhat 4 antibiotics are considered directly nephrotoxic?1. Aminoglycosides (Gentamicin 300mg) 2. Amphotericin B 3. Sulfonamides 4. VancomycinWhat 4 immunosuppressants are considered directly nephrotoxic?1. Cyclosporin 2. Methotrexate 3. Tacrolimus 4. Mitomycin_______normally cause vasodilation of the afferent arterioles of the glomeruli. This helps maintain normal glomerular perfusion and glomerular filtration rate (GFR), an indicator of renal function. This is particularly important in renal failure where the kidney is trying to maintain renal perfusion pressure by elevated ________levels. At these elevated levels it also constricts the afferent arteriole into the glomerulus in addition to the efferent arteriole it normally constricts.Prostaglandins Angiotensin II_______ is a prostaglandin inhibitor which interferes with prostaglandin-associated intrinsic vasodilation, a well known cause of drug-induced ARF. In patients at risk and in patients with preexisting renal dysfunction, its use must be avoided.Ketorolac NSAIDs cause unopposed constriction of the afferent arteriole and decreased renal perfusion pressure.Acute decline in kidney function that is often reversible occurring in hospitalized patients.Acute kidney Injury (AKI)