Genitourinary

1
Genitourinary
2
Renal Function

• Kidney receives-20 - 25 of cardiac output
• Glomerular filtration rate (GFR) 125 ml/min
  (normal young adult)
• Urine output 1500-2400 ml/24 hr

3
Renal Function Tests

• Blood Urea Nitrogen(BUN) -normal value 10
  - 20 mg/dl -renal dysfunction gt 50
  mg/dl Plasma Creatinine
  -normal value 0.7 - 1.5 mg/dl Creatinine
  clearance -normal value 110 -
  150 ml/min

4
Renal InsufficiencyThreshold loss of 60 of
nephrons Uremia loss of 90 of nephrons
5
Effects of Anesthetic Drugs on Renal Function

• Decreases RBF, GFR, and urinary output
• Nephrotoxicity (Fluoride ions)

6
Common Etiology of Renal Failure

• Chronic glomerulonephritis
• Diabetic nephropathy
• Pyelonephritis

7
Chronic Renal Failure Due to Circulatory
Changes

• Anemia (erythropoietin deficiency)
• Coagulopathy Platelet dysfunction
• Systemic heparinization
• Hypertension (renin release)
• Vasoconstriction (angiotensin II)
• Sodium retention (aldosterone)

8
Chronic Renal FailureMetabolic Changes

• Metabolic acidosis (phosphate, sulfate
  retention)
• Hyperkalemia
• Hypermagnesemia
• Hypocalcemia ( secondary to phosphate retention)

9
Chronic Renal FailureImmunosuppressionDecreased
phagocyte activityEffects of drugs
10
Postoperative ProblemsChronic Renal Failure

• Recurarization
• Hypertension
• Sensitivity to opioids
• Cardiac dysrhythmias

11
Causes of Perioperative OliguriaPrerenal
(Decreased RBF)

• Hypovolemia during anesthesia
• Decreased cardiac output during anesthesia

12
Causes of Perioperative Oliguria Renal (Acute
Tubular Necrosis)

• Renal ischemia
• Nephrotoxic drugs
• Myoglobinuria
• Hemoglobinuria

13
Causes of Perioperative Oliguria Postrenal
(Obstructive Uropathy)

• Bilateral ureteral obstruction
• Extravasation from bladder rupture
• Prostatism

14
Differential Dx Perioperative Oliguria

• Prerenal RenalUrine
  sodium lt 40 gt 40 Urine
  osmolarity gt 400 250-300 Urine/plasma gt
  1 . 8 lt 1 . 1

15
Patients at Risk of Perioperative Renal Failure
Renal disease Multiple trauma
Liver disease
Congestive Heart Failure Hypovolemia
Sepsis Advanced age
16
Operative Risks of Renal FailureAbdominal
aneurysm resection Cardiopulmonary bypass
17
Treatment of Acute Renal Failure

• Fluid Challenge 250 cc
• Dopamine infusion (3-5 mcg/kg/min)
• Diuretics Mannitol 12.5 gms Furosemide 5 mg

18
Renal Disease

• Glomerulonephritis Acute common following
  post-streptococcal
• Goodpasture syndrome (vasculitis)
• Nephrotic syndrome gross roteinuria
• Interstitial nephritis (drug allergy)

19
Renal Disease

• Polycystic kidneys
• Fanconi syndrome
• Bartter syndrome
• Renal hypertension
• Uric acid nephropathy
• Hepatorenal syndrome

20
Anesthesia for ESWL

• Regional Analgesia to T6
• LMA /TIVA
• Drip Propofol
• Drip Remifentanil

21
TURP Syndrome

• Cardiovascular changes
• hypervolemia
• CNS disturbances
• Dysrhythmias
• (dilutional hyponatremia)

22
TURP SyndromeSigns of Hemodilution

• Serum sodium lt 120 mEg/L
• Decrease Hematocrit
• Alter mentation
• Restlessness

23
Anesthesia for TURP

• Early detection of excessive fluid absorption
• Early detection of bladder perforation
• Postoperative analgesia (opioid)
• Spinal preferred (level to T 10)

24
Renal TransplantationPreoperative

• Hemodialysis preoperative
• Confirm Electrolytes
• Confirm Hemoglobin

25
Renal Transplantation Intraoperative

• Fluid 5 glucose with 0.45 NaCl(D5 1/2NS)
• Mannitol 12.5 gm increments
• Avoid Blood Transfusions

26
Fluid Management

• Preoperative hydration (balanced salt solution
  10-20 ml/kg)
• Intraoperatively 3-5 ml/kg/hr
• Maintain urine output gt 0.5 ml/kg/hr
• Avoid diuretics

27
Fluid Management(Anuric Patient)Replace
insensible losses with D5W
28
Anesthetic Induction

• CNS hypersensitivity
• Hypovolemic
• Electrolyte imbalance

29
Renal TransplantationHazards and
Complications

• Cardiac arrest (acute hyperkalemia)
• Acute immunologic rejection (DIC)
• Hematoma
• Delayed signs of rejection (fever, oliguria)

30
Autonomic Hyperreflexia

• Spinal cord lesion above T 6
• When a painful stimuli occurs the intact nervous
  responses by intense vasoconstriction increasing
  blood pressure.heart reacts by slowing down
  (Bainbridge reflex). and the blood vessels
  attempt to dilatea war between the
  vasoconstriction, vessel dilation, high BP and
  slow heart rate ensuesfix it or a stroke will
  occur!!

31
Autonomic HyperreflexiaTriggers

• Distended bladder
• Stimulated rectum
• Uterine contractions
• Pelvic infection
• Pressure ulcers
• thrombophelbitis

32
Autonomic HyperreflexiaSymptoms

• Headache
• Red face
• Slow heart rate
• Blurred vision
• Very high BP
• Sweating
• Nasal congestion nausea/vomiting

33
Autonomic Hyperreflexia

• Remove the stimulus
• Treat the afferent limb with analgesia
• Treat the efferent limb with ganglionic
  blockersalpha-adrenergic antagonists or direct
  acting vasodilators
• Pearls of ammonia old time remedy that works
  wonders