The document discusses anesthesia considerations for patients with renal disease undergoing various genitourinary surgeries. It covers the effects of anesthetic agents on renal function, as well as positioning techniques and their physiologic impacts. Guidelines are provided for preoperative evaluation, induction, maintenance, fluid management, and specific procedures like TURP to safely anesthetize patients with renal impairment.
anaesthestic implications in a case of chronic kidneydiseaseShameek Datta
The document defines chronic kidney disease as structural or functional kidney damage lasting over three months, as evidenced by a glomerular filtration rate of less than 60 ml/min/1.73m2. It then classifies chronic kidney disease into 5 stages based on glomerular filtration rate. The leading causes of chronic kidney disease are listed as diabetic glomerular disease (30%), glomerulonephritis, hypertensive nephropathy, and primary glomerulopathy with hypertension. Complications of chronic kidney disease are described across multiple body systems including cardiovascular, metabolic, musculoskeletal, endocrine, gastrointestinal, immune, and neurological systems.
Effects of anesthesia and surgery on renal functionHASSAN RASHID
THIS PRESENTATION DISCUSSES IN BRIEF THE VARIOUS EFFECT OF ANAESTHESIA AND SURGERY ON RENAL FUNCTIONS. IT ALSO DISCUSSED THE PROTECCTIVE EFFECTS OF ANAESTHETIC AGENTS ON KIDNEY DURING THE PERIOPERATIVE PERIOD,
Renal physiology and its anesthetic implicationsSathya Prabu
This document discusses renal anatomy, physiology, and function testing. It begins with an overview of renal anatomy including kidney location, blood supply, nephron structure, and juxtaglomerular apparatus. It then covers renal physiology such as blood flow, glomerular filtration, regulation of GFR, tubular reabsorption and secretion, and urine concentration and dilution. Finally, it discusses renal function testing including tests of glomerular filtration rate like creatinine clearance and measures of tubular function like the concentration and dilution tests.
Anesthesia in Transurethral resection of prostateAshish Dhandare
1) The document discusses preoperative considerations and risks for anesthesia in transurethral resection of the prostate (TURP), with a focus on risks in elderly patients.
2) It provides details on TURP syndrome, a cluster of symptoms caused by absorption of irrigating fluid during surgery, and treatments for TURP syndrome and its complications like glycine toxicity, hemolysis, hypothermia, and bleeding.
3) Factors that can minimize risks of TURP syndrome are limiting surgery duration to under 1 hour, maintaining fluid bag height below 60cm, frequent bladder drainage, and careful surgical technique to preserve prostatic capsule integrity. Spinal anesthesia is recommended for its benefits in T
This document discusses the anatomy, physiology, and functions of the liver as they relate to anesthesia. It begins with an overview of hepatic anatomy including gross and microscopic structure, blood supply, and drainage. It then covers hepatic blood flow regulation by intrinsic and extrinsic factors and how anesthesia can affect blood flow. The major sections discuss hepatic functions such as metabolism, synthesis, and detoxification. In particular, it notes the liver's roles in glucose regulation, protein and lipid metabolism, coagulation factor production, and bilirubin metabolism.
This document discusses anesthesia considerations for in vitro fertilization (IVF). It outlines the IVF process and notes that oocyte retrieval is a stressful, painful component. The role of the anesthesiologist is to provide pain relief, proper medical history evaluation, and counseling to reduce patient anxiety. Various anesthesia techniques are described, including monitored anesthesia care, general anesthesia, regional techniques, and total intravenous anesthesia. Factors like medication interactions, obesity, and medical comorbidities require special consideration. The goal of anesthesia is to provide adequate pain relief while using agents and techniques that minimize potential negative effects on fertility and pregnancy outcomes.
Intro to Hypoxic pulmonary vasoconstriction Arun Shetty
Hypoxic pulmonary vasoconstriction, a seldom heard phenomenon but very effective physiologic property which helps lungs utilise ventilation to the maximum
Anaesthesia to patiens with liver disease or a liver transplantscanFOAM
A presentation by Anna Januszkiewicz at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
anaesthestic implications in a case of chronic kidneydiseaseShameek Datta
The document defines chronic kidney disease as structural or functional kidney damage lasting over three months, as evidenced by a glomerular filtration rate of less than 60 ml/min/1.73m2. It then classifies chronic kidney disease into 5 stages based on glomerular filtration rate. The leading causes of chronic kidney disease are listed as diabetic glomerular disease (30%), glomerulonephritis, hypertensive nephropathy, and primary glomerulopathy with hypertension. Complications of chronic kidney disease are described across multiple body systems including cardiovascular, metabolic, musculoskeletal, endocrine, gastrointestinal, immune, and neurological systems.
Effects of anesthesia and surgery on renal functionHASSAN RASHID
THIS PRESENTATION DISCUSSES IN BRIEF THE VARIOUS EFFECT OF ANAESTHESIA AND SURGERY ON RENAL FUNCTIONS. IT ALSO DISCUSSED THE PROTECCTIVE EFFECTS OF ANAESTHETIC AGENTS ON KIDNEY DURING THE PERIOPERATIVE PERIOD,
Renal physiology and its anesthetic implicationsSathya Prabu
This document discusses renal anatomy, physiology, and function testing. It begins with an overview of renal anatomy including kidney location, blood supply, nephron structure, and juxtaglomerular apparatus. It then covers renal physiology such as blood flow, glomerular filtration, regulation of GFR, tubular reabsorption and secretion, and urine concentration and dilution. Finally, it discusses renal function testing including tests of glomerular filtration rate like creatinine clearance and measures of tubular function like the concentration and dilution tests.
Anesthesia in Transurethral resection of prostateAshish Dhandare
1) The document discusses preoperative considerations and risks for anesthesia in transurethral resection of the prostate (TURP), with a focus on risks in elderly patients.
2) It provides details on TURP syndrome, a cluster of symptoms caused by absorption of irrigating fluid during surgery, and treatments for TURP syndrome and its complications like glycine toxicity, hemolysis, hypothermia, and bleeding.
3) Factors that can minimize risks of TURP syndrome are limiting surgery duration to under 1 hour, maintaining fluid bag height below 60cm, frequent bladder drainage, and careful surgical technique to preserve prostatic capsule integrity. Spinal anesthesia is recommended for its benefits in T
This document discusses the anatomy, physiology, and functions of the liver as they relate to anesthesia. It begins with an overview of hepatic anatomy including gross and microscopic structure, blood supply, and drainage. It then covers hepatic blood flow regulation by intrinsic and extrinsic factors and how anesthesia can affect blood flow. The major sections discuss hepatic functions such as metabolism, synthesis, and detoxification. In particular, it notes the liver's roles in glucose regulation, protein and lipid metabolism, coagulation factor production, and bilirubin metabolism.
This document discusses anesthesia considerations for in vitro fertilization (IVF). It outlines the IVF process and notes that oocyte retrieval is a stressful, painful component. The role of the anesthesiologist is to provide pain relief, proper medical history evaluation, and counseling to reduce patient anxiety. Various anesthesia techniques are described, including monitored anesthesia care, general anesthesia, regional techniques, and total intravenous anesthesia. Factors like medication interactions, obesity, and medical comorbidities require special consideration. The goal of anesthesia is to provide adequate pain relief while using agents and techniques that minimize potential negative effects on fertility and pregnancy outcomes.
Intro to Hypoxic pulmonary vasoconstriction Arun Shetty
Hypoxic pulmonary vasoconstriction, a seldom heard phenomenon but very effective physiologic property which helps lungs utilise ventilation to the maximum
Anaesthesia to patiens with liver disease or a liver transplantscanFOAM
A presentation by Anna Januszkiewicz at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
This document summarizes guidelines from the 4th Edition of the American Society of Regional Anesthesia and Pain Medicine on the anesthetic management of patients receiving various antithrombotic therapies. It outlines recommendations regarding neuraxial blocks and catheter management for patients taking medications such as thrombolytics, unfractionated heparin, low molecular weight heparin, and newer oral anticoagulants. The guidelines provide evidence-based recommendations on timing of blocks and catheter removal in relation to medication dosing and coagulation status monitoring. They emphasize the importance of interdisciplinary communication and individualized clinical decision making to minimize risks while providing optimal pain management.
Obesity presents unique challenges for anaesthesia. Obese patients have decreased lung volumes which increases the risk of hypoxemia during induction and intubation. Preoxygenation in a slightly head-up position can help reduce this risk. Intubation may be difficult due to obesity related anatomical changes. Regional anaesthesia can also be challenging due to obscured landmarks and extensive adipose tissue. Postoperatively, obese patients are at higher risk of respiratory failure, DVT, and wound infections requiring close monitoring. Careful consideration of dosing, positioning, and postoperative monitoring is needed to safely manage anaesthesia for obese patients.
Anesthesia for Liver transplantation - Dr.Sandeepdeepmbbs04
Liver transplantation is a complex procedure that requires careful anaesthetic management due to the pathophysiological changes associated with end-stage liver disease. Key considerations include monitoring for haemodynamic instability, coagulopathy and metabolic disturbances. Frequent intraoperative monitoring and correction of abnormalities are important to assess graft function and optimize patient outcomes.
Chronic kidney disease is defined as kidney damage or decreased kidney function (GFR <60mL/min/1.73m^2) for more than 3 months. It is staged based on GFR from stage 1 to 5. Major causes include diabetes and hypertension. Patients experience cardiovascular, respiratory, immune, electrolyte, gastrointestinal, endocrine, hematological, neurological and acid-base abnormalities due to decreased kidney function. Anesthesia management focuses on optimizing fluid, acid-base, electrolyte and hemodynamic status as well as modifying dosages based on creatinine clearance. Regional techniques may be used but prolonged bleeding time is a contraindication.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Cerebral physiology and effects of anaesthetic agentsRicha Kumar
The document discusses cerebral physiology and the effects of anesthetic agents. It covers topics such as:
- Anatomy of the cerebral circulation including the circle of Willis.
- Regulation of cerebral blood flow including chemical, myogenic, and neurogenic factors.
- Effects of increased intracranial pressure on cerebral perfusion.
- How different anesthetic agents like barbiturates, propofol, etomidate, narcotics, benzodiazepines, ketamine, and volatile anesthetics affect cerebral blood flow and cerebral metabolic rate.
The document discusses various patient positioning techniques used in anaesthesia and their goals, risks, and complications. It describes positions like supine, lithotomy, prone, lateral decubitus, and their effects on cardiovascular and respiratory systems. Common risks include nerve injuries, pressure sores, compartment syndrome, and visual complications. Careful patient assessment, padding of pressure points, monitoring for nerve injuries are emphasized. Position changes should be gradual and extremities checked regularly during long procedures to prevent injuries.
The document discusses renal impairment in anesthesia, including acute kidney injury (AKI) and chronic kidney disease (CKD). It covers the definition, causes, and staging of AKI and CKD. Pre-operative management of patients with renal impairment focuses on optimizing fluid, electrolyte and acid-base status. Intra-operatively, reduced doses of medications may be needed due to impaired drug clearance. Regional anesthesia offers advantages over general anesthesia when possible. Careful post-operative monitoring of fluid balance and renal function is also emphasized.
1) Chronic renal failure results from the progressive deterioration of renal function due to diseases like diabetes and hypertension. It is defined as kidney damage or a glomerular filtration rate less than 60 mL/min/1.73 m2 for more than 3 months.
2) Anesthetic management of chronic renal failure patients requires special considerations due to electrolyte imbalances, unpredictable fluid status, cardiac disease, and slower drug clearance. Induction and maintenance agents must be chosen and dosed carefully to avoid large decreases in blood pressure.
3) Postoperative monitoring is important due to risks of muscle weakness from incomplete drug reversal, cardiac issues from hyperkalemia, and respiratory depression from opioid accumulation in these patients.
This document provides an overview of anesthesia considerations for laparoscopic surgeries. It discusses the history of laparoscopy, physiological effects of pneumoperitoneum including on the cardiovascular, respiratory, central nervous and renal systems. It also outlines respiratory complications like subcutaneous emphysema, pneumothorax, gas embolism and their treatment. The effects of patient positioning and conduct of anesthesia are summarized.
This document provides information on interscalene brachial plexus blocks, including indications, contraindications, anatomy, techniques, complications, and references. It describes Winnie's anterior approach using landmarks to identify the interscalene groove for injection, as well as a posterior approach. Areas of blockade, continuous techniques, and use of nerve stimulation are also summarized. Supraclavicular blockade as an alternative is outlined with similar details.
Elderly patients represent the fastest growing population globally. They experience many age-related physiological changes that increase surgical risk. Preoperative evaluation and optimization is important to identify risks like cardiovascular disease and pulmonary issues. Anesthesia in the elderly requires lower doses of induction agents and opioids due to pharmacokinetic changes. Regional anesthesia may provide benefits over general anesthesia. Close postoperative monitoring is needed due to risks of complications like delirium, cognitive dysfunction, hypotension, and hypothermia.
Anaesthetic considerations in diabetes mellitus (1)hassam2
The document discusses anaesthetic considerations for patients with diabetes mellitus. It notes that the preanesthesia evaluation should include assessing the patient's type of diabetes, level of blood glucose control, and medication regimen. It also discusses implications for different types of diabetes, implications of regional anesthesia, diabetic complications like nephropathy and implications for airway management. The document provides guidance on adjustments to insulin regimens prior to surgery depending on the patient's usual insulin doses and risk of hypoglycemia.
1. The document discusses the physiology of inhalational anesthetic agents, including their history, potency measured by MAC values, factors affecting uptake and distribution, and theories of anesthetic action.
2. It provides background on the discovery and use of important agents as well as their blood:gas and tissue:blood partition coefficients which determine how rapidly they enter the blood and tissues.
3. The uptake and distribution of agents depends on alveolar ventilation, cardiac output, tissue blood flow and the arterial-tissue pressure gradient, with highly perfused tissues like the brain reaching equilibrium most rapidly.
Liver transplantation involves complex anesthesia management due to physiological changes from cirrhosis and transplantation. Key aspects include invasive hemodynamic monitoring, management of coagulopathy and fluid shifts, and intensive care of recipients post-operatively due to risks of primary nonfunction, bleeding, infection and renal failure. Outcomes have improved dramatically with advances like cyclosporine in 1979 and living donor transplantation, with 1-year survival rates now over 90% for liver transplantation.
This document discusses obstructive jaundice and Whipple's operation. It provides information on:
1) The physiological functions of the liver including glucose homeostasis, fat and protein metabolism, drug and hormone metabolism, bilirubin formation and excretion, and its role as a blood reservoir.
2) How obstructive jaundice affects liver function and can lead to endotoxemia, systemic alterations to circulatory homeostasis like hypotension, and effects on the renal system like hypoperfusion.
3) Considerations for anesthetic management for a patient undergoing Whipple's operation to address obstructive jaundice, given the liver's role and how its dysfunction impacts other organ systems.
This document discusses the anesthetic considerations for patients with hypothyroidism. Key points include:
- Hypothyroidism can cause difficult airway management, cardiovascular instability, and hypothermia risks intraoperatively.
- Patients require cautious sedation, induction, and hemodynamic monitoring due to effects on circulation and metabolism.
- In pregnancy, hypothyroidism increases risks of complications for both mother and baby, so euthyroid state through levothyroxine is important.
- Myxedema coma is a rare severe form treated with intravenous thyroid replacement and intensive care support.
1) The document discusses preoperative evaluation and anesthetic considerations for thoracic surgery patients, with a focus on patients undergoing one-lung ventilation.
2) Key points of preoperative evaluation include assessing pulmonary function, cardiac status, investigating the extent of lung involvement, and optimizing patients with respiratory conditions like COPD.
3) Anesthetic management focuses on techniques for one-lung ventilation using devices like double-lumen endotracheal tubes, as well as strategies for ventilation, induction, and analgesia tailored to patient comorbidities.
Effect of Anesthesia and Surgery on Renal System.pptxGanta Ranganath
Both anesthesia and surgery can affect renal function through hemodynamic changes and stress responses. Anesthetics like volatile agents can decrease glomerular filtration rate through effects on renal blood flow and perfusion pressure. Muscle relaxants may cause transient hypotension. Intravenous agents generally have minor direct renal effects. Colloids like albumin are renoprotective while hydroxyethyl starch and dextran can cause acute kidney injury. Drugs that alter hemodynamics like NSAIDs, ACE inhibitors, and positive pressure ventilation can also impact renal function. Surgery induces stress responses and fluid shifts that can lead to prerenal azotemia. Specific procedures like pneumoperitoneum, cardiopulmonary bypass, aortic cross
Pharmacokinetic changes in renal impairment and dosage considerationsDr Htet
The kidneys play a key role in drug elimination from the body. Renal impairment can affect the pharmacokinetics of many drugs by reducing their excretion, increasing their bioavailability and toxicity. Dosage regimens must be adapted based on a patient's level of renal function and whether the drug or its metabolites are renally excreted. Drugs that are nephrotoxic or have a narrow therapeutic index require especially close monitoring and dosage adjustment according to glomerular filtration rate in patients with renal impairment.
This document summarizes guidelines from the 4th Edition of the American Society of Regional Anesthesia and Pain Medicine on the anesthetic management of patients receiving various antithrombotic therapies. It outlines recommendations regarding neuraxial blocks and catheter management for patients taking medications such as thrombolytics, unfractionated heparin, low molecular weight heparin, and newer oral anticoagulants. The guidelines provide evidence-based recommendations on timing of blocks and catheter removal in relation to medication dosing and coagulation status monitoring. They emphasize the importance of interdisciplinary communication and individualized clinical decision making to minimize risks while providing optimal pain management.
Obesity presents unique challenges for anaesthesia. Obese patients have decreased lung volumes which increases the risk of hypoxemia during induction and intubation. Preoxygenation in a slightly head-up position can help reduce this risk. Intubation may be difficult due to obesity related anatomical changes. Regional anaesthesia can also be challenging due to obscured landmarks and extensive adipose tissue. Postoperatively, obese patients are at higher risk of respiratory failure, DVT, and wound infections requiring close monitoring. Careful consideration of dosing, positioning, and postoperative monitoring is needed to safely manage anaesthesia for obese patients.
Anesthesia for Liver transplantation - Dr.Sandeepdeepmbbs04
Liver transplantation is a complex procedure that requires careful anaesthetic management due to the pathophysiological changes associated with end-stage liver disease. Key considerations include monitoring for haemodynamic instability, coagulopathy and metabolic disturbances. Frequent intraoperative monitoring and correction of abnormalities are important to assess graft function and optimize patient outcomes.
Chronic kidney disease is defined as kidney damage or decreased kidney function (GFR <60mL/min/1.73m^2) for more than 3 months. It is staged based on GFR from stage 1 to 5. Major causes include diabetes and hypertension. Patients experience cardiovascular, respiratory, immune, electrolyte, gastrointestinal, endocrine, hematological, neurological and acid-base abnormalities due to decreased kidney function. Anesthesia management focuses on optimizing fluid, acid-base, electrolyte and hemodynamic status as well as modifying dosages based on creatinine clearance. Regional techniques may be used but prolonged bleeding time is a contraindication.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Cerebral physiology and effects of anaesthetic agentsRicha Kumar
The document discusses cerebral physiology and the effects of anesthetic agents. It covers topics such as:
- Anatomy of the cerebral circulation including the circle of Willis.
- Regulation of cerebral blood flow including chemical, myogenic, and neurogenic factors.
- Effects of increased intracranial pressure on cerebral perfusion.
- How different anesthetic agents like barbiturates, propofol, etomidate, narcotics, benzodiazepines, ketamine, and volatile anesthetics affect cerebral blood flow and cerebral metabolic rate.
The document discusses various patient positioning techniques used in anaesthesia and their goals, risks, and complications. It describes positions like supine, lithotomy, prone, lateral decubitus, and their effects on cardiovascular and respiratory systems. Common risks include nerve injuries, pressure sores, compartment syndrome, and visual complications. Careful patient assessment, padding of pressure points, monitoring for nerve injuries are emphasized. Position changes should be gradual and extremities checked regularly during long procedures to prevent injuries.
The document discusses renal impairment in anesthesia, including acute kidney injury (AKI) and chronic kidney disease (CKD). It covers the definition, causes, and staging of AKI and CKD. Pre-operative management of patients with renal impairment focuses on optimizing fluid, electrolyte and acid-base status. Intra-operatively, reduced doses of medications may be needed due to impaired drug clearance. Regional anesthesia offers advantages over general anesthesia when possible. Careful post-operative monitoring of fluid balance and renal function is also emphasized.
1) Chronic renal failure results from the progressive deterioration of renal function due to diseases like diabetes and hypertension. It is defined as kidney damage or a glomerular filtration rate less than 60 mL/min/1.73 m2 for more than 3 months.
2) Anesthetic management of chronic renal failure patients requires special considerations due to electrolyte imbalances, unpredictable fluid status, cardiac disease, and slower drug clearance. Induction and maintenance agents must be chosen and dosed carefully to avoid large decreases in blood pressure.
3) Postoperative monitoring is important due to risks of muscle weakness from incomplete drug reversal, cardiac issues from hyperkalemia, and respiratory depression from opioid accumulation in these patients.
This document provides an overview of anesthesia considerations for laparoscopic surgeries. It discusses the history of laparoscopy, physiological effects of pneumoperitoneum including on the cardiovascular, respiratory, central nervous and renal systems. It also outlines respiratory complications like subcutaneous emphysema, pneumothorax, gas embolism and their treatment. The effects of patient positioning and conduct of anesthesia are summarized.
This document provides information on interscalene brachial plexus blocks, including indications, contraindications, anatomy, techniques, complications, and references. It describes Winnie's anterior approach using landmarks to identify the interscalene groove for injection, as well as a posterior approach. Areas of blockade, continuous techniques, and use of nerve stimulation are also summarized. Supraclavicular blockade as an alternative is outlined with similar details.
Elderly patients represent the fastest growing population globally. They experience many age-related physiological changes that increase surgical risk. Preoperative evaluation and optimization is important to identify risks like cardiovascular disease and pulmonary issues. Anesthesia in the elderly requires lower doses of induction agents and opioids due to pharmacokinetic changes. Regional anesthesia may provide benefits over general anesthesia. Close postoperative monitoring is needed due to risks of complications like delirium, cognitive dysfunction, hypotension, and hypothermia.
Anaesthetic considerations in diabetes mellitus (1)hassam2
The document discusses anaesthetic considerations for patients with diabetes mellitus. It notes that the preanesthesia evaluation should include assessing the patient's type of diabetes, level of blood glucose control, and medication regimen. It also discusses implications for different types of diabetes, implications of regional anesthesia, diabetic complications like nephropathy and implications for airway management. The document provides guidance on adjustments to insulin regimens prior to surgery depending on the patient's usual insulin doses and risk of hypoglycemia.
1. The document discusses the physiology of inhalational anesthetic agents, including their history, potency measured by MAC values, factors affecting uptake and distribution, and theories of anesthetic action.
2. It provides background on the discovery and use of important agents as well as their blood:gas and tissue:blood partition coefficients which determine how rapidly they enter the blood and tissues.
3. The uptake and distribution of agents depends on alveolar ventilation, cardiac output, tissue blood flow and the arterial-tissue pressure gradient, with highly perfused tissues like the brain reaching equilibrium most rapidly.
Liver transplantation involves complex anesthesia management due to physiological changes from cirrhosis and transplantation. Key aspects include invasive hemodynamic monitoring, management of coagulopathy and fluid shifts, and intensive care of recipients post-operatively due to risks of primary nonfunction, bleeding, infection and renal failure. Outcomes have improved dramatically with advances like cyclosporine in 1979 and living donor transplantation, with 1-year survival rates now over 90% for liver transplantation.
This document discusses obstructive jaundice and Whipple's operation. It provides information on:
1) The physiological functions of the liver including glucose homeostasis, fat and protein metabolism, drug and hormone metabolism, bilirubin formation and excretion, and its role as a blood reservoir.
2) How obstructive jaundice affects liver function and can lead to endotoxemia, systemic alterations to circulatory homeostasis like hypotension, and effects on the renal system like hypoperfusion.
3) Considerations for anesthetic management for a patient undergoing Whipple's operation to address obstructive jaundice, given the liver's role and how its dysfunction impacts other organ systems.
This document discusses the anesthetic considerations for patients with hypothyroidism. Key points include:
- Hypothyroidism can cause difficult airway management, cardiovascular instability, and hypothermia risks intraoperatively.
- Patients require cautious sedation, induction, and hemodynamic monitoring due to effects on circulation and metabolism.
- In pregnancy, hypothyroidism increases risks of complications for both mother and baby, so euthyroid state through levothyroxine is important.
- Myxedema coma is a rare severe form treated with intravenous thyroid replacement and intensive care support.
1) The document discusses preoperative evaluation and anesthetic considerations for thoracic surgery patients, with a focus on patients undergoing one-lung ventilation.
2) Key points of preoperative evaluation include assessing pulmonary function, cardiac status, investigating the extent of lung involvement, and optimizing patients with respiratory conditions like COPD.
3) Anesthetic management focuses on techniques for one-lung ventilation using devices like double-lumen endotracheal tubes, as well as strategies for ventilation, induction, and analgesia tailored to patient comorbidities.
Effect of Anesthesia and Surgery on Renal System.pptxGanta Ranganath
Both anesthesia and surgery can affect renal function through hemodynamic changes and stress responses. Anesthetics like volatile agents can decrease glomerular filtration rate through effects on renal blood flow and perfusion pressure. Muscle relaxants may cause transient hypotension. Intravenous agents generally have minor direct renal effects. Colloids like albumin are renoprotective while hydroxyethyl starch and dextran can cause acute kidney injury. Drugs that alter hemodynamics like NSAIDs, ACE inhibitors, and positive pressure ventilation can also impact renal function. Surgery induces stress responses and fluid shifts that can lead to prerenal azotemia. Specific procedures like pneumoperitoneum, cardiopulmonary bypass, aortic cross
Pharmacokinetic changes in renal impairment and dosage considerationsDr Htet
The kidneys play a key role in drug elimination from the body. Renal impairment can affect the pharmacokinetics of many drugs by reducing their excretion, increasing their bioavailability and toxicity. Dosage regimens must be adapted based on a patient's level of renal function and whether the drug or its metabolites are renally excreted. Drugs that are nephrotoxic or have a narrow therapeutic index require especially close monitoring and dosage adjustment according to glomerular filtration rate in patients with renal impairment.
This document discusses how various diseases can affect drug pharmacokinetics and metabolism. It covers effects of gastrointestinal, cardiac, renal, liver and thyroid disorders. Key points include:
- Renal and liver diseases can significantly impact drug absorption, distribution, metabolism and excretion. Dose adjustments are often needed.
- Cardiac failure can alter drug distribution and decrease elimination due to reduced hepatic and renal perfusion.
- Monitoring drug levels can help optimize therapy for individual patients, especially when inter-individual variability is high or clinical effects are difficult to assess. Close monitoring of response is important when prescribing for patients with organ dysfunction.
This document discusses how drugs are eliminated by the kidneys and the mechanisms of renal injury caused by various drugs. It notes that many drugs can injure the kidneys through a few common mechanisms, such as altering renal blood flow or causing direct tubular toxicity. It provides examples of specific drugs that can cause these types of renal injuries. The document also discusses factors that influence drug dosing in patients with renal impairment and principles for safely prescribing drugs in such patients.
ANAESTHESIA FOR PATIENTS WITH RENAL FAILURE.pptxSweetPotatoe1
The document discusses renal failure and its implications for anesthesia. It describes the functions of the kidneys and defines acute kidney injury and chronic kidney disease. For patients with renal impairment, pre-operative optimization is important, including fluid management and electrolyte correction. Regional anesthesia is preferred over general anesthesia when possible due to better hemodynamic stability. Careful monitoring is needed during and after surgery to watch for fluid overload, electrolyte abnormalities, and other complications.
Hepatic Considerations In Oral Surgery .pptxSudiptaBera9
This document provides an overview of considerations for oral surgery in patients with liver disease. It discusses the functional role of the liver and risks associated with dental care for patients with liver disease such as impaired hemostasis, drug interactions, and increased susceptibility to infection. It also covers preoperative evaluation including liver function tests and coagulation assessment. Guidelines are provided for preoperative management including vitamin K replacement, drug dosing adjustments based on liver function, and anesthesia considerations. Postoperative management focuses on hemostasis and infection control.
The kidney plays an important role in regulating fluids, electrolytes, and removing waste from the body. Impairment of kidney function affects drug pharmacokinetics. Common causes of kidney failure include disease, injury, drug toxicity, infections, diabetes, toxins, and reduced blood flow. Acute kidney problems or trauma can lead to uremia where filtration is impaired, causing excess fluid and waste to accumulate. Uremic patients may have changes in drug absorption, distribution, and clearance. Dosage adjustments are often needed based on a patient's kidney function and drug properties to safely treat uremic patients.
Management of acute kidney injury (AKI) involves several common principles including optimizing hemodynamics, correcting fluid and electrolyte imbalances, discontinuing nephrotoxic medications, and dose adjusting other medications. Treatment depends on the underlying cause of AKI and may involve managing life-threatening complications, diagnosing and treating the underlying condition, and renal replacement therapies like hemodialysis or peritoneal dialysis. Prevention efforts focus on recognizing at-risk patients and using preventive measures to avoid AKI. The prognosis of AKI depends on the specific cause and presence of other factors, with prerenal azotemia and postrenal azotemia generally having a better prognosis than other forms of intrinsic AKI.
Alcoholic liver disease is a result of over-consuming alcohol that damages the liver, leading to a buildup of fats, inflammation, and scarring. It can be fatal.
This document discusses the pathophysiology, treatment, and pharmacology of gout. It covers the following key points:
1) Gout is caused by the buildup of uric acid crystals in the joints due to high levels of uric acid in the blood. It discusses the biochemical pathway involved in uric acid production.
2) Treatment involves managing acute gout attacks with NSAIDs or colchicine, and lowering uric acid levels long-term with xanthine oxidase inhibitors like allopurinol and febuxostat, or uricosuric drugs like probenecid.
3) Colchicine provides rapid relief of gout attacks but has gastrointestinal side
What is Hepatic Encephalopathy.
What is the Grading of Hepatic Encephalopathy.
How to Diagnose Hepatic Encephalopathy .
How to Treat Hepatic Encephalopathy.
Lect 6 physiological principles of the renalSaidi Wazir
This document discusses acute renal failure (ARF). It defines ARF and describes its pathophysiology, which can be prerenal, intrinsic, postrenal, or functional. Clinical presentation depends on setting but can include edema, colored urine, and hypotension. Treatment involves preventing ARF through avoiding nephrotoxins, maximizing renal perfusion, and controlling risk factors. For established ARF, management supports the patient through the recovery period with renal replacement therapy, fluid management with diuretics, and electrolyte and nutrition management. Drug dosing is also challenging in ARF patients.
Drug use in hepatic and renal impairmentAkshil Mehta
- Drugs are more likely to accumulate and cause toxicity in patients with impaired liver or kidney function due to reduced drug metabolism and excretion. The pharmacokinetics of many drugs are altered in patients with hepatic or renal impairment.
- In liver disease, drug absorption, metabolism, protein binding, and elimination can all be affected. Dosage reductions are often required for drugs that are metabolized by the liver. Hepatotoxic drugs should be avoided when possible.
- In kidney disease, drug absorption and excretion may be altered. Drugs that are weak acids or bases can be "trapped" in the urine through changes in urine pH. Dosage adjustments are often needed for drugs excreted by
This document discusses commonly used drugs that require dosage adjustment or caution in patients with chronic kidney disease (CKD). It notes that around 50% of patients with an estimated glomerular filtration rate (eGFR) below 60 mL/min experience drug-related adverse events, with risks increased in those who are non-white, older, have diabetes, or more advanced CKD. Common adverse events reported include hypoglycemia, falling, nausea, hyperkalemia, and confusion. Several classes of drugs like NSAIDs, sodium phosphate preparations, iodinated contrast, gadolinium, antibiotics, antihypertensives, and lipid-lowering drugs require caution or dosage adjustment in CKD. The document emphasizes reviewing medications for
- Hepatorenal syndrome (HRS) is a form of kidney failure seen in patients with cirrhosis or acute liver failure. It is caused by severe renal vasoconstriction due to excessive vasodilation in the splanchnic circulation.
- There are two main types - type 1 is rapidly progressive over 2 weeks and has a very poor prognosis, type 2 progresses more slowly over weeks/months.
- Treatment options include TIPS to reduce portal hypertension, midodrine/octreotide to constrict vessels, terlipressin which is effective but can cause ischemia, and liver transplantation which is curative but limited by organ availability.
Hepatorenal syndrome is a condition characterized by impaired renal function in patients with advanced liver disease and portal hypertension. There are two types - type 1 is rapid and progressive, leading to death within a month without treatment, while type 2 is less severe but still associated with worse prognosis. The pathogenesis involves splanchnic vasodilation triggering renal vasoconstriction. Treatment involves vasoconstrictors like terlipressin combined with albumin to increase mean arterial pressure and improve renal function. Achieving at least a 10 mmHg increase in MAP with vasoconstrictor therapy correlates with better renal outcomes in hepatorenal syndrome patients.
The document discusses the treatment of heart failure in patients with chronic kidney disease. It notes that CKD is a common comorbidity in heart failure patients and that the coexistence of the two conditions increases health risks. The main treatments discussed are:
1. ACE inhibitors and ARBs to improve ventricular function, though they can worsen kidney function. Close monitoring of kidney function and electrolytes is needed.
2. Beta blockers like bisoprolol and carvedilol to improve ventricular function, though they can cause hypotension and kidney dysfunction.
3. Aldosterone antagonists to reduce heart failure worsening and increase survival, though they can cause hyperkalemia and worsen kidney function.
This study evaluated the safety and efficacy of adding the SGLT2 inhibitor dapagliflozin to furosemide for treating decompensated heart failure in patients with type 2 diabetes and reduced ejection fraction. 100 patients were randomized to receive either dapagliflozin plus furosemide or placebo plus furosemide. The addition of dapagliflozin improved diuresis parameters, reduced body weight and dyspnea scores to a greater extent than furosemide alone, with minimal effects on renal function or electrolyte levels. The results indicate that dapagliflozin enhances the diuretic effect of furosemide and may improve outcomes for patients with heart failure
Transplant patient for non TRANSPLANT SURGERYArun Krishna
This document discusses considerations for anaesthesia in patients who have undergone renal transplantation and require non-transplant surgery. Key points include:
1. Renal transplant patients have altered physiology due to immunosuppression and the transplanted organ. Their renal function is usually reduced which can impact drug metabolism and excretion.
2. The main anesthetic goal is to maintain renal perfusion and prevent hypotension, hypovolemia and hypoxia which could further compromise renal function.
3. Immunosuppressive drugs and their interactions, side effects and toxicity must be considered. Maintaining adequate immunosuppression is also important to prevent organ rejection in the perioperative period.
Similar to Anesthesia for Patients with Renal Disease.pptx (20)
The document discusses acid-base balance and disorders. It defines acids and bases, and explains how the body maintains acid-base balance through buffers, respiratory regulation, and renal regulation. It describes the four major acid-base disorders: respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis. For each disorder it provides the primary cause, effects on bicarbonate and pH levels, and examples of compensatory mechanisms and potential treatments.
This document provides information on intraosseous vascular access. It discusses indications for IO insertion including cardiac arrest, deteriorating patient, trauma, and inability to obtain IV access. It reviews safe insertion of the EZ-IO needle including equipment, sites, and steps. Potential risks and complications are outlined. Drugs and fluids that can be administered via IO are noted. Practical tips are provided such as pushing fluids due to resistance. Patient safety tips emphasize obtaining definitive venous access when possible and removing the IO.
This document discusses the cardiovascular, respiratory, renal, hepatic, and other physiologic effects of pneumoperitoneum during laparoscopic surgery. Pneumoperitoneum, or insufflation of carbon dioxide gas into the abdominal cavity, can cause hemodynamic changes such as decreased venous return and cardiac output. It can also decrease lung volumes and impair respiratory function. These effects are more pronounced in elderly or debilitated patients undergoing laparoscopic surgery. The document emphasizes the importance of intraoperative monitoring and management strategies to optimize patient hemodynamics and ventilation during pneumoperitoneum, especially in high-risk patients.
Physiologic changes during pregnancy.pptxTadesseFenta1
Physiological changes during pregnancy alter the body's response to anesthesia. These changes begin early in pregnancy and progress significantly. By term, there are reductions in MAC values (up to 40%), sensitivity to local anesthetics (up to 30%), and FRC (up to 20%). Pregnant women also experience increased oxygen consumption (20-50%), minute ventilation (40-50%), cardiac output (up to 50%), blood volume (45%), and risk of aspiration. Anesthesia requires accounting for these changes through techniques like left uterine displacement, preoxygenation, and rapid sequence induction.
This document discusses medical ethics and key concepts. It defines ethics as a system of moral principles that affect decision making. Medical ethics applies these principles to medicine and considers patients' rights and welfare. The four basic principles of medical ethics are respect for autonomy, non-maleficence, beneficence, and justice. Effective communication is important for maintaining ethics and professionalism in healthcare. Anesthesiologists must thoughtfully communicate with patients throughout the perioperative process to respect patient autonomy and fulfill their professional duties.
Anesthetic Management of Abdominal Surgery.pptxTadesseFenta1
This document outlines an anesthesia course for abdominal and genitourinary surgery. The course aims to enable anesthetists to safely manage anesthesia for patients undergoing abdominal, gastrointestinal, hepatobiliary, anal, and genitourinary surgeries. It covers preoperative evaluation, risks associated with abdominal surgery, anesthetic techniques for different procedures, postoperative complications, and management of patients with hepatic or cardiovascular disease. The course assessments include assignments, quizzes, and a final written exam.
Anesthesia for Genitourinary Surgery.pptxTadesseFenta1
This document provides information about anesthesia for genitourinary surgeries and procedures. It discusses considerations for cystoscopy, transurethral resection of the prostate (TURP), lithotripsy, and the lithotomy position. Regional or general anesthesia is typically used depending on the procedure and patient factors. Complications of TURP can include hemorrhage, TURP syndrome from fluid absorption, bladder perforation, hypothermia, septicemia, and disseminated intravascular coagulation. Careful monitoring is important to detect issues like fluid overload and hyponatremia.
This document outlines an EMT training course on advanced airway management and the use of the pharyngeal esophageal airway device (PEAD), also known as the Combitube. The agenda covers respiratory anatomy and physiology, respiratory volumes and management, assessing respiratory problems, respiratory/cardiac arrest management, basic airway techniques, suctioning, and the use of dual-lumen airway devices like the Combitube. Objectives are provided for each lesson, which include demonstrating techniques like Combitube insertion and ensuring correct placement. Practical skills testing with a physician is also mentioned.
This document provides an overview of respiratory physiology, including:
- The structures and functions of the respiratory system
- The mechanics of breathing involving the lungs, chest wall, diaphragm and pleura
- The respiratory center in the brainstem that controls breathing
- Gas exchange that occurs between the alveoli and blood in the lungs
- Factors that impact ventilation and perfusion matching in the lungs
- Definitions of various lung volumes and capacities measured in respiratory physiology
The document discusses regional anesthesia techniques including central nerve blocks like spinal, epidural, and caudal anesthesia as well as peripheral nerve blocks. It provides detailed anatomy of the spinal column and spinal cord. It describes the techniques for performing spinal and epidural anesthesia including patient positioning, skin preparation, needle placement, and assessment of the block. Factors affecting the spread and level of the block are also discussed.
This document discusses thoracic anesthesia and includes outlines of topics, objectives, and details on preoperative evaluation, preparation, intraoperative monitoring, physiology of the lateral decubitus position under different conditions, and management of one-lung ventilation. Specifically, it covers assessing the surgical patient, optimizing medical conditions preoperatively, important intraoperative monitors, how induction of anesthesia and opening the chest impact ventilation and perfusion in the lateral position, and goals of managing one-lung ventilation.
The document discusses common renal pathologies and their management in the perioperative period. It covers acute renal failure (ARF), chronic renal failure (CRF), diabetic nephropathy, nephrotic syndrome, glomerulonephritis, and pyelonephritis. ARF is classified as prerenal, intrinsic, or postrenal based on etiology. CRF results in fluid and electrolyte abnormalities, cardiac and pulmonary issues, and anemia. Diabetic nephropathy is caused by hypertension and hyperglycemia damaging the kidneys over time. Treatment focuses on controlling blood sugar and hypertension.
This document discusses the pathophysiology and management of burn patients. It covers:
1) Major burns cause massive tissue destruction and inflammatory response, leading to burn shock from fluid shifts and systemic effects if >20% TBSA.
2) Burns trigger a hypermetabolic response for weeks, with increased cardiac work and protein catabolism impairing healing.
3) Resuscitation follows the Parkland formula to replace fluid losses. Fluid management aims to maintain urine output and prevent organ dysfunction.
The document discusses airway anatomy and equipment for airway management. It reviews the anatomy of the upper airway from the nose to the bronchi and describes key differences in pediatric anatomy. Common airway equipment is outlined including laryngoscopes, endotracheal tubes, face masks, and laryngeal mask airways. Effective face mask ventilation techniques are also summarized.
The operating room poses hazards including physical (back injury, fire), chemical (anesthetic gases, cleaning agents), and biological (infectious materials, needle sticks) risks. Regulations and guidelines aim to minimize these dangers. Grounding systems prevent electric shocks to patients, while fire risks are reduced by separating fuels, heat sources, and oxygen. Catastrophic events like anaphylaxis and malignant hyperthermia require immediate interventions - anaphylaxis treatment includes epinephrine, while malignant hyperthermia involves dantrolene, cooling, and oxygen administration. The resuscitation trolley must contain appropriate drugs to manage emergencies.
The document provides information on instrument processing, including the steps involved in decontamination, cleaning, sterilization, and high-level disinfection. It describes the learning objectives, introduces key terms, and discusses various chemical disinfectants and their appropriate uses. Specific processes and best practices are outlined for decontamination using chlorine solutions, cleaning instruments, sterilization using various methods like steam, dry heat and chemicals, and high-level disinfection through boiling, steaming or chemicals. Factors that impact effectiveness and proper techniques, concentrations, exposure times are emphasized throughout.
The document provides guidelines for infection prevention and control in operating theatres. It discusses principles like considering all people potentially infectious, hand hygiene, use of personal protective equipment (PPE) like gloves, gowns and masks. It describes different types of PPE and when they should be used. Surgical scrubs and maintaining asepsis are also outlined, including inspecting hands for cuts, removing jewelry, adjusting masks and scrubs lasting 5 minutes with specific techniques. Strict personal hygiene is necessary for operating room workers to prevent transmission of infections.
The document outlines the organization and personnel roles in the operating room (OR). It discusses the physical areas of the OR including design, equipment, and traffic flow. It describes the roles of the sterile team including the surgeon, assistants, and scrub nurse who maintain the sterile field. The roles of the unsterile team including the anesthesia provider and circulating nurse who prepare supplies and equipment are also outlined. Specific responsibilities for each role in pre-operative, intra-operative, and post-operative periods are provided. Item counts are performed before and after procedures for patient and personnel safety.
Perioperative Pain Management by abe 2018.pptTadesseFenta1
The document discusses acute and chronic pain management. It covers definitions of pain, physiology of pain including pathways and modulation, assessment of pain, classification of pain as acute or chronic and nociceptive or neuropathic. It also discusses importance of treating acute perioperative pain to reduce complications and enhance recovery while balancing risks of adverse effects from overtreatment of pain. Management of both acute and chronic pain is an important objective of the course.
This document discusses fluid management and replacement during anesthesia. It describes how the body's fluid is divided into compartments and how dehydration can occur from fasting or fluid loss. It provides a formula to calculate a patient's fasting fluid deficit based on weight and time fasting. It also explains how to calculate fluid maintenance needs, insensible fluid loss, and additional fluids needed based on the level of surgical trauma. The goal is to replace all fluid losses to maintain adequate intravascular volume and prevent complications during and after surgery.
How to Manage Reception Report in Odoo 17Celine George
A business may deal with both sales and purchases occasionally. They buy things from vendors and then sell them to their customers. Such dealings can be confusing at times. Because multiple clients may inquire about the same product at the same time, after purchasing those products, customers must be assigned to them. Odoo has a tool called Reception Report that can be used to complete this assignment. By enabling this, a reception report comes automatically after confirming a receipt, from which we can assign products to orders.
How to Create a Stage or a Pipeline in Odoo 17 CRMCeline George
Using CRM module, we can manage and keep track of all new leads and opportunities in one location. It helps to manage your sales pipeline with customizable stages. In this slide let’s discuss how to create a stage or pipeline inside the CRM module in odoo 17.
Level 3 NCEA - NZ: A Nation In the Making 1872 - 1900 SML.pptHenry Hollis
The History of NZ 1870-1900.
Making of a Nation.
From the NZ Wars to Liberals,
Richard Seddon, George Grey,
Social Laboratory, New Zealand,
Confiscations, Kotahitanga, Kingitanga, Parliament, Suffrage, Repudiation, Economic Change, Agriculture, Gold Mining, Timber, Flax, Sheep, Dairying,
Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...EduSkills OECD
Andreas Schleicher, Director of Education and Skills at the OECD presents at the launch of PISA 2022 Volume III - Creative Minds, Creative Schools on 18 June 2024.
8+8+8 Rule Of Time Management For Better ProductivityRuchiRathor2
This is a great way to be more productive but a few things to
Keep in mind:
- The 8+8+8 rule offers a general guideline. You may need to adjust the schedule depending on your individual needs and commitments.
- Some days may require more work or less sleep, demanding flexibility in your approach.
- The key is to be mindful of your time allocation and strive for a healthy balance across the three categories.
Creative Restart 2024: Mike Martin - Finding a way around “no”Taste
Ideas that are good for business and good for the world that we live in, are what I’m passionate about.
Some ideas take a year to make, some take 8 years. I want to share two projects that best illustrate this and why it is never good to stop at “no”.
A Free 200-Page eBook ~ Brain and Mind Exercise.pptxOH TEIK BIN
(A Free eBook comprising 3 Sets of Presentation of a selection of Puzzles, Brain Teasers and Thinking Problems to exercise both the mind and the Right and Left Brain. To help keep the mind and brain fit and healthy. Good for both the young and old alike.
Answers are given for all the puzzles and problems.)
With Metta,
Bro. Oh Teik Bin 🙏🤓🤔🥰
2. • renal pathophysiololgy
– The effect of anesthetic agent and Muscle relaxant
– technique on renal function
– Positioning on renal surgery
• Anesthesia for Genitourinary Surgery (7hrs)
– Kidney transplantation
– Lithotripsy
– Percutaneous ultrasonic lithotripsy
– Extra corporeal shock wave lithotripsy
– Prostatectomy
– Trans-vesical resection
– Trans-urethral resection
3. Anesthesia and surgery has an effect directly or
indirectly on the renal surgery
Direct effects
All inhalational and many iv induction agents
cause
Myocardial depression
Hypotension
Increased renal vascular resistance
Effect – decreased RBF
_ decreased GFR, then decreased UOP
4. • In direct effects ;
Of a great consern
direct toxicity of fluorinated agent
Fluoride ion :- inhibit metabolic process
Cause proximal tubular swelling & necrosis
Affect urine concentrated ability
5. Altered Renal Function & the Effects of
Anesthetic Agent
Intravenous Agents
Propofol & Etomidate
• The pharmacokinetics of both propofol and etomidate
are not significantly affected by impaired renal function.
Decreased protein binding of etomidate in patients with
hypoalbuminemia may enhance its pharmacological
effects.
6. Barbiturates
• Patients with renal disease often exhibit increased
sensitivity to barbiturates during induction, even
though pharmacokinetic profiles appear to be
unchanged. The mechanism appears to be an
increase in free circulating barbiturate as a result of
decreased protein binding. Acidosis may also favor a
more rapid entry of these agents into the brain by
increasing the nonionized fraction of the drug
7. Ketamine
• Ketamine pharmacokinetics are minimally altered
by renal disease. Some active hepatic metabolites
are dependent on renal excretion and can
potentially accumulate in renal failure.
Ketamine's secondary hypertensive effect may be
undesirable in hypertensive renal patients.
8. Benzodiazepines
• Benzodiazepines undergo hepatic metabolism and
conjugation prior to elimination in urine. Because
most are highly protein bound, increased sensitivity
may be seen in patients with hypoalbuminemia.
Diazepam should be used cautiously in the presence
of renal impairment because of a potential for the
accumulation of active metabolites.
9. Opioids
• Most opioids currently in use in anesthetic management
are inactivated by the liver; some of these metabolites
are then excreted in urine. The accumulation of
morphine (morphine-6-glucuronide) and meperidine
metabolites has been reported to prolong respiratory
depression in some patients with renal failure. Increased
levels of normeperidine, a meperidine metabolite, have
been associated with seizures. The pharmacokinetics of
the most commonly used opioid agonist–antagonists
(butorphanol, nalbuphine, and buprenorphine) are
unaffected by renal failure.
10. Anticholinergic Agents
• In doses used for premedication, atropine and
glycopyrrolate can generally be used safely in
patients with renal impairment. Because up to 50%
of these drugs and their active metabolites are
normally excreted in urine, however, the potential
for accumulation exists following repeated doses.
Scopolamine is less dependent on renal excretion,
but its central nervous system effects can be
enhanced by azotemia.
11. Phenothiazines, H2 Blockers, & Related Agents
• Most phenothiazines, such as promethazine, are
metabolized to inactive compounds by the liver.
Although pharmacokinetic profiles are not
appreciably altered by renal impairment,
potentiation of their central depressant effects by
azotemia can also occur
• All H2-receptor blockers are very dependent on renal
excretion. Metoclopramide is partly excreted
unchanged in urine and will also accumulate in renal
failure
12. Inhalation Agents
Volatile Agents
• Volatile anesthetic agents are nearly
ideal for patients with renal dysfunction
because of their lack of dependence on
the kidneys for elimination, their ability
to control blood pressure, and generally
minimal direct effects on renal blood
flow .
13. • Although patients with mild to moderate renal
impairment do not exhibit altered uptake or
distribution, accelerated induction and
emergence may be seen in severely anemic
patients (hemoglobin < 5 g/dL) with chronic
renal failure; this observation may be
explained by a decrease in the blood:gas
partition coefficient or a decrease in minimum
alveolar concentration.
14. • Enflurane and sevoflurane (with < 2 L/min gas
flows) are considered undesirable for patients
with renal disease undergoing long
procedures because of the potential for
fluoride accumulation .
• Methoxyflourane ???????
15. Nitrous Oxide
• Many clinicians omit or limit the use of nitrous oxide
to 50% in patients with renal failure in an attempt to
increase arterial oxygen content in the presence of
anemia.
• This rationale may be justified only in severely
anemic patients (hemoglobin < 7 g/dL), in whom
even a small increase in the dissolved oxygen content
may represent a significant percentage of the arterial
to venous oxygen difference.
16. Muscle Relaxants
Succinylcholine
• Succinylcholine can be safely used in the presence of
renal failure, provided the serum potassium
concentration is known to be less than 5 mEq/L at the
time of induction. When the serum potassium is higher
or is in doubt, a nondepolarizing muscle relaxant should
be used instead.
• Although decreased pseudocholinesterase levels have
been reported in a few uremic patients following dialysis,
significant prolongation of neuromuscular blockade is
rarely seen.
17. Cisatracurium, Atracurium, & Mivacurium
• Mivacurium is minimally dependent on the kidneys
for elimination. Minor prolongation of effect may be
observed due to reduced plasma
pseudocholinesterase. Cisatracurium and atracurium
are degraded in plasma by enzymatic ester hydrolysis
and nonenzymatic Hofmann elimination. These
agents may be the drugs of choice for muscle
relaxation in patients with renal failure.
18. Vecuronium & Rocuronium
• The elimination of vecuronium is primarily hepatic,
but up to 20% of the drug is eliminated in urine. The
effects of large doses of vecuronium (> 0.1 mg/kg)
are only modestly prolonged in patients with renal
insufficiency. Rocuronium primarily undergoes
hepatic elimination, but prolongation by severe renal
disease has been reported.
19. Pancuronium, Pipecuronium, Alcuronium,
& Doxacurium
• These agents are all primarily dependent on renal
excretion (60–90%). Although pancuronium is
metabolized by the liver into less active
intermediates, its elimination half-life is still
primarily dependent on renal excretion (60–80%).
Neuromuscular function should be closely
monitored if these agents are used in patients
with abnormal renal function.
20. Metocurine, Gallamine, & Decamethonium
• All three agents are almost entirely dependent on renal
excretion for elimination and should generally be avoided
in patients with impaired renal function.
Reversal Agents
• Renal excretion is the principal route of elimination for
edrophonium, neostigmine, and pyridostigmine. The half-
lives of these agents in patients with renal impairment are
therefore prolonged at least as much as any of the above
relaxants. Problems with inadequate reversal of
neuromuscular blockade are usually related to other factors
.
21. Anesthesia for Patients with Renal
Failure
Preoperative Considerations
ARF
CRF
Manifestations of Renal Failure
Metabolic
Hematological
Cardiovascular
Pulmonary
Endocrine
Gastrointestinal
Neurological
22. Preoperative Evaluation
o In Patients with acute renal failure a Optimal
perioperative management is dependent on
preoperative dialysis.
o In Patients with chronic renal failure regardless of the
procedure or the anesthetic employed, complete
evaluation is required to make certain that they are in
optimal medical condition; all reversible
manifestations of uremia should be controlled.
Preoperative dialysis on the day of surgery or on the
previous day is usually necessary.
23. o Physical and laboratory evaluation should focus on
both cardiac and respiratory functions
• Arterial blood gas analysis is useful in detecting
hypoxemia and evaluating acid–base status
• The electrocardiogram should be examined carefully for
signs of hyperkalemia or hypocalcemia as well as
ischemia, conduction blocks, and ventricular
hypertrophy
• Signs of fluid overload or hypovolemia should be
sought . Intravascular volume depletion often results
from overzealous dialysis.
24. o Preoperative red blood cell transfusions should
generally be given only to severely anemic
patients (hemoglobin < 6–7 g/dL) or when
significant intraoperative blood loss is expected.
25. o A bleeding time and coagulation studies are
advisable, particularly if regional anesthesia is
being considered. Serum electrolyte, BUN, and
creatinine measurements can assess the adequacy
of dialysis.
o Preoperative drug therapy should be carefully
reviewed for drugs with significant renal
elimination . Dosage adjustments and
measurements of blood levels (when available)
are necessary to prevent drug toxicity.
26. Premedication
– Alert patients who are relatively stable can be given
reduced doses of an opioid or a benzodiazepine.
Promethazine, 12.5–25 mg intramuscularly, is a useful
adjunct for additional sedation and for its antiemetic
properties.
– Aspiration prophylaxis with an H2 blocker may be
indicated in patients with nausea, vomiting, or
gastrointestinal bleeding . Metoclopramide, 10 mg
orally or slowly intravenously, may also be useful in
accelerating gastric emptying, preventing nausea, and
decreasing the risk of aspiration
27. Intraoperative Considerations
Monitoring
• Intraarterial, central venous, and pulmonary artery
monitoring are often indicated, particularly for patients
undergoing procedures associated with major fluid shifts
• Direct intraarterial blood pressure monitoring may also be
indicated in poorly controlled hypertensive patients regardless
of the procedure
• Aggressive invasive monitoring may be indicated, particularly
in diabetic patients with advanced renal disease undergoing
major surgery; this group of patients may have up to 10 times
the perioperative morbidity of diabetic patients without renal
disease
28. Induction
• Patients with nausea, vomiting, or gastrointestinal
bleeding should undergo rapid-sequence induction
with cricoid pressure
• The dose of the induction agent should be reduced in
debilitated or critically ill patients.
• Thiopental, 2–3 mg/kg, or propofol, 1–2 mg/kg, is
often used. Etomidate, 0.2–0.4 mg/kg, may be
preferable in hemodynamically stable patients.
• Ketamine , 1-2 kg for hemodynamically unstable pts
if pts are not hypertensive.
29. • An opioid, beta-blocker (esmolol), or lidocaine
may be used to blunt the hypertensive response
to intubation .
• Succinylcholine, 1.5 mg/kg, can be used for
endotracheal intubation if the serum potassium
is less than 5 mEq/L.
• Rocuronium (0.6 mg/kg), cisatracurium (0.15
mg/kg), atracurium (0.4 mg/kg), or mivacurium
(0.15 mg/kg) should be used for intubating
patients with hyperkalemia.
30. • Vecuronium, 0.1 mg/kg, may be a suitable
alternative, but some prolongation of its
effects should be expected.
• Use of a laryngeal mask airway, when
appropriate , usually avoids the excessive
sympathetic (hypertensive) response
sometimes associated with intubation and the
need for muscle paralysis.
31. Maintenance
• The ideal maintenance technique should be able to
control hypertension with minimal effects on cardiac
output, because an increase in cardiac output is the
principal compensatory mechanism for anemia.
• Volatile anesthetics, nitrous oxide, propofol, fentanyl,
sufentanil, alfentanil, remifentanil, hydromorphone,
and morphine are generally regarded as satisfactory
maintenance agents.
• Isoflurane and desflurane may be the preferred
volatile agents because they have the least effect on
cardiac output .
32. • Nitrous oxide should be used cautiously in
patients with poor ventricular function and
should probably not be used in patients with very
low hemoglobin concentrations (< 7 g/dL) to
allow the administration of 100% oxygen .
• Meperidine may not be a good choice because of
the accumulation of normeperidine . Morphine
may be used, but some prolongation of its effects
should be expected.
• Controlled ventilation should be considered for
patients with renal failure.
33. • Inadequate spontaneous ventilation with
progressive hypercarbia under anesthesia can
result in respiratory acidosis that may
exacerbate preexisting acidemia, lead to
potentially severe circulatory depression, and
dangerously increase serum potassium
concentration
34. Fluid theraphy
• Superficial operations involving minimal tissue
trauma require replacement of only insensible
fluid losses with 5% dextrose in water.
• Procedures associated with major fluid losses or
shifts require isotonic crystalloids, colloids, or
both .
• Lactated Ringer's injection is best avoided in
hyperkalemic patients when large volumes of
fluid may be required, because it contains
potassium (4 mEq/L); normal saline may be used
instead.
35. • Glucose-free solutions should generally be used
because of the glucose intolerance associated
with uremia.
• Blood that is lost should generally be replaced
with packed red blood cells.
• Blood transfusion either has no effect or may be
beneficial for patients in renal failure who are
candidates for renal transplant; transfusion may
decrease the likelihood of rejection following
renal transplantation in some patients
38. Commonly used position in urologic
surgery
• Lithotomy position
– Use
– Physiologic effects
• Trendelenburg
– Use
– Physiologic effects
• Lateral /kidney rest/flank
– Use
– Physiologic effects
– Complication
40. Cystoscopy
• Important to evaluate for treatment or diagnosis or
both
• Indication – hematurea, pyuria, trauma, cancer,
obstruction, calculi
• Anesthesia – dilatation of urethra , ureter, bladder,
by dilator are painful w/c needs anesthesia. Perhaps
some patients tolerate it.
41. • Choice of anesthesia
– With out anesthesia
– LA/cream/spray/jelly
– GA, slight sedation, ketamine &diazepam or opoids
– RA – SA
– Upper tract instrumentation – T-6 block
– Lower tract instrumentation - T-10 block
42. Hydrocelectomy , orchidopexy,
orchidectomy
• Indication
– Congenital neoplasm
– Testicular torsion
• Anesthesia
– RA – T-9 block is required for orchidopexy/ectomy
– GA – in children
43. Trans urethral resection of the
prostate (TURP)
• Its performed by special instrument called a
resectoscope (instrument having an electrode
capable for transmitting both cutting and
coagulating currents) with out incision simply
by inserting.
• Is often preceded by cystoscopy
• Continuous irrigating fluid is used to distend
the bladder and to wash away blood and
dissected prostatic tissue.
44. Irrigating fluids
• Distilled water
– Provide least interference with visibility but
absorption of large amount of water can lead to
excessive dilutional hyponatremia which results in
hemolysis of RBC, water intoxication and CNS
symptoms ranging from confusion to convulsion
and coma.
– So distilled water is abandoned
45. • Electrolyte solution
– NS/RL do least harm when absorbed into
circulation , but they are highly ionized and
promote dispersion of high current from
resectoscope .
46. • Non-electrolyte solution consisting sorbitol
and Mannitol(cytal) or glycin 1.5%
– Which are slightly hypo osmolar to the blood
– Have been used most often
– Since the prostate gland contains large venous
sinuses, it is inevitable that irrigating solutions will
be absorbed.
47. • The volume of irrigating fluids absorbed depend
on
– Hydrostatic pressure deriving fluid in to prostatic veins
and sinuses which is determined by
• Height of container must>60cm
• Cystoscopic site
• Flow rate
– Experience and technique of surgeon
• Maximum duration 1-2hrs
• Amount is proportional to duration
• 10- 30 ml /min of resection.
48. – Number /size of venous sinuses opened during
resection
• Ideal irrigating solutions for TURP are iso-osmolar,
weakly or non ionized, non- hemolytic, transparent ,
non – metabolized , non –toxic , rapidly excreted and
inexpensive
• But there is no ideal irrigating fluid
• Now a day’s most common irrigating fluid for TURP are
– Glycin and Mannitol
49. Anaesthesia management
o GA/SA
• Patients are old with co – existing disease
• Patient should not move , other wise
sphincter perforation.
General anaesthesia
– Adequate depth to prevent coughing & movement
– Movement cause bladder / prostate capsule
perforation , so increase bleeding
– Disadvantage of GA is it masks early symptoms of
TURP syndrome
50. Regional anesthesia
Advantages
• Improves sugical exposure – bladder atony
• Easier to detect TURP syndrome because patient is
awake
• More rapid hemostasis
• Reduce operative blood loss
• Decrease RBF
51. COMPLICATION OF TURP
I. TURP syndrome (water intoxication
syndrome)
Syndrome due to excessive absorption of
irrigating fluid
• Reflects absorption of excessive amount of
irrigating fluids leading to
a) Dilutional hyponatremia
b) Hypervolumia
c) Hypo-osmolarity
d) Adverse hemodynamic and CVS changes
52. Sign and symptom
During RA
Awake patient initially xzed by headache ,
confusion, N/V, dizziness, restlessness,
hypertension, stupor, seizure, coma,
bradycardia, skeletal muscle twiching
All signs and symptoms are effects of
irrigating fluids
53. During GA
Less specific , unexplained tachycardia or bradycardia,
pulmonary edema , cardiac dysarrhythmia,
ECG evidence occurs when – when Na+ < 115 meq/l
- widen QRS
complex
- elevation of ST
segment
54. CNS symptoms
-significant when serum Na+ <120
meq/l
-confusion, restelessness,
dizziness, coma
-visual disturbance
55. • Treatment
– Notify the surgeon
– Stop the surgery as soon as possible
– Fluid restriction
– Diuretics – to remove excess fluid
– Administer Na+ with careful measurement
• 0.9% N/S – conc Na+ > 120 meq/l
• 3% N/S – conc Na+ < 120 meq/l
56. II. Perforation of the bladder
can be due to
• Difficult resection made by cutting loop
• Over distention of bladder by irrigating fluid
• In adequate anesthesia
Perforation of prostatic capsule is suspected if the
irrigation fluid fails to return as it should
.
57. Management
1. Generally excreted by the kidney
2. Catheter drainage
3. Surprapubic drainage best, most
efficient for removing collecting fluid
58. III. Bactermia/sepsis /fever
– Common occurrence following TURP
– Prostatitis should be controlled prior to surgery
– Sudden cardio vascular collapse folllowing TURP is the
most common sign and symptom
Treatment
Broad spectrum antibiotics
59. IV. Blood loss
Estimation of blood loss is difficult (
15ml/mi/gm of prostate
Blood loss is related to
Vascularity of the gland
Surgeon technique and experience
Weight of prostate gland
Length of operation
60. Treatment
Blood , fluid
Blood transfusion should be based on pre op hct ,
clinical assessment of the patient , duration /
difficulty of resection
Generally prostate mass 30-80 gm;2 unit and if
>80gm ; 4 unit of blood should be prepared
61. V. Hypothermia
Older patients has thermoregulatory impairment
due to decline in autonomic nervous system
Elderly patients tolerate hypothermia poorly
Causes ; -irrigating with cold fluid
-intravenous absorption of fluid
-cold operating room
-GA
62. Prevention and treatment
Use warm irrigating or iv fluid
Heating the room
Cover the patient with blanket
Oxygen administration
Analgesic like ……..
63. Open prostatectomy
• Can be performed through supra/retro pubic
or perineal approach
• Mostly in supine position
• The choice of using open or TURP is depend
on the size of the prostate
– Prostate gland >60-80gm are conventionally
removed by open prostatectomy to reduce the
morbidity associated with TURP
64. • Anesthesia consideration
– The choice of anesthesia is influenced by status of
patient (CVS/PS & mental status )
– Uncooperative confused patient need GA
– GA
• Control of ventilation of lung
• Ensuring adequate oxygenation
65. – RA
• Simple to administer
• Post op analgesia
• Reduce operative blood loss
• Lessen post op agitation and restlessness
– Post op complication
• Blood loss
• Nerve injury
• DVT
• Blockage of irrigation
66. Nephrectomy
• Indication
– neoplasm / renal tumor – most common
– Hydronephrosis
– Chronic infection of the kidney
– Trauma
– Cystic/caliculi disease of the kidney
– Transplantation of the kidney
67. • Anesthesia
– GA in lateral / flank position
– Preoperative
• Asses renal function
• Anemia may accompany impaired renal function
– Patient require ETTI
– Pay attention for position of the upper and lower
limbs insert a cotton b/n the legs on the knee
and ankle , pad pressure points
68. – Good relaxation is important
– Better to use atracurium or mivacurium
– Do not use pancuronium and gallamine
– EBL~500 ml
– Duration ~ 2-3 hrs
69. – As the legs are dependent, venous return
decreasesthis may be exacerbated by kinking the
inferior venacava as a result of the position of the
kidney
– After positioning of the patient correct placement of
ETT should be checked , incase inadvertent extubation
or endobronchial intubation has been occurred
– Complication
• Nerve injury
• Hypotension
• pneumothorax
70. • Pylolithotomy
– Removal of renal pelvic stone
– Anesthesia same as nephrectomy
• Penilectomy
– Removal of penis
– GA (prepare blood)
71. • Minor procedures
A. Circumcision – surgical removal of the foreskin
B. Phimosis – contraction of the prepuce usually
treated by circumcision
C. Paraphimosis – retraction of the prepuce
behined the glans penis with inability to restore
it to the normal position
Anesthesia (A-C)
All are children
Mask induction with pre cordial stethoscope
72. • Epispadia
– A congenital malformation in which the urethra
opens on the dorsum of the penis
• Hypospadia
– Malformation of the lower wall of the urethra, so
that the urethra opens on the under surface of the
penis
Anesthesia
– GA with ETTI or SA
73. Home take message
• Always you should change your anesthetic
management according to the status of the
particular patient. You may intubate a patient
even if it is done for most of the patients with
only halothane and mask. Rigidity should be
avoided in anesthesia.
75. Extracorporeal Shock Wave
Lithotripsy
• What is shock wave lithotripsy?
– Shock Wave Lithotripsy (SWL) is the most common
treatment for kidney stones &uretral stone in the
U.S. Shock waves from outside the body are
targeted at a kidney stone causing the stone to
fragment. The stones are broken into tiny pieces.
lt is sometimes called ESWL: Extracorporeal Shock
Wave Lithotripsy.
76. • These are what the words mean:
ESWL
–extracorporeal: from outside the body
– shock waves: pressure waves
– lithotripsy (the Greek roots of this word are "litho"
meaning stone, "tripsy" meaning crushed)
77. • ESWL a nonsurgical technique for treating stones in
the kidney or ureter (the tube going from the kidney
to the bladder) using high-energy shock waves.
Stones are broken into "stone dust" or fragments
that are small enough to pass in urine. lf large pieces
remain, another treatment can be performed
78. • Very large stones cannot be treated this way.
• The size and shape of stone, where it is lodged
in your urinary tract, your health, and your
kidneys' health will be part of the decision to
use it.
• Stones that are smaller than 2 cm in diameter
are the best size for SWL. The treatment might
not be effective in very large ones.
79. • SWL is contraindicated
– In the following pts
– Because x-rays and shock waves are needed in
SWL,
– pregnant women with stones are not treated this
way.
– People with bleeding disorders,
– infections,
80. • severe skeletal abnormalities, or who are
morbidly obese also not usually good
candidates for SWL.
• lf your kidneys have other abnormalities,
• lf you have a cardiac pacemaker,
81. • What does the treatment involve?
– Pts will be positioned on an operating table. A
soft, water-filled cushion may be placed on your
abdomen or behind your kidney.
– The body is positioned so that the stone can be
targeted precisely with the shock wave. In an
older method, the patient is placed in a tub of
lukewarm water.
82. • About 1-2 thousand shock waves are needed to
crush the stones. The complete treatment takes
about 45 to 60 minutes
• Sometimes, insert a tube via the bladder and thread
it up to the kidney just prior to SWL. These tubes
(called stents) are used when the ureter is blocked,
when there is a risk of infection and in patients with
intolerable pain or reduced kidney function.
83. • After the procedure, you will usually stay for
about an hour then be allowed to return home if
all goes well.
• You will be asked to drink plenty of liquid, strain
your urine through a filter to capture the stone
pieces for testing, and you may need to take
antibiotics and painkillers.
• Some studies have reported stones may come
out better if certain drugs (calcium antagonists or
alpha-blockers) are used after SWL
84.
85. • Does the patient need anesthesia?
– General anaesthesia (GA) for SWL treatment offers
optimized pain control and controlled respiratory
excursion. This creates optimal conditions for
stone targeting and consecutive fragmentation. In
modern anesthetic practice, GA is considered to
be safe with a low morbidity. However, it seems
preferable to avoid, if not mandatory, especially in
high-risk patients.
86. • Disadvantages are the need to involve an
anesthetic specialist and the need for
postoperative recovery, increasing the overall
costs and making GA less suitable in the
common outpatient SWL setup of most
urological departments. Solely in children or in
extremely anxious patients, it is still the
preferred option.
87. • Other potential indications are particularly
long treatments as in patients with bilateral
stones, concomitant renal and ureteral stones
or in patients with very hard calculi (cystine,
calcium oxalate monohydrate, or brushite),
which are known to be resistant to
fragmentation and require high, potentially
painful energy levels
88. • Inhalation Anaesthesia with Nitrous
OxideNitrous oxide is a medical anesthetic gas
and on the market as Entonox, a mixture of 50%
nitrous oxide and 50% oxygen.
• It was discovered in 1776 by Joseph Priestly [18]
and constitutes another analgesic option for SWL
treatment. This colourless gas is highly soluble in
blood and the arterial concentration reaches a
plateau 10 minutes after commencing the
inhalation.
89. • It diffuses rapidly through the cellular
membranes, does no bind to haemoglobin,
and is eliminated unchanged via the lungs.
The analgesic effect commences 20 to 30
seconds after inhalation and a peak effect is
reached after 3 to 5 minutes.
90. • Reflexes of coughing and airway protection are
not noticeable altered [18]. This rapid onset and
quick loss of effect make nitrous oxide an
attractive option for day-case procedures.
• Especially in treatments of short duration such as
SWL, Entonox can be used in spontaneously
breathing patients to provide analgesia.
Regarding its analgesic effect, the concentration
of 30% of nitrous oxide is reported to be
equivalent to 10–15 mg of morphine
91. • Adverse effects of Entonox are mainly transient
nausea and light headedness. A further issue can
be slight cardiac depression; therefore, the gas
should be used carefully in patients with
congestive heart failure and in those with
obstructive airway disease [20]. It is
contraindicated in patients with pathological air-
filled body cavities (pneumothorax or obstructed
bowels) as nitrous oxide is diffusing into these,
consecutively increasing volume and pressure
therein.
92. • The use of Entonox during SWL was reported in
only one RCT study up to now; 150 patients
undergoing treatment where randomized into 3
groups, one to receive Entonox, the other to have
intravenous pethidine, and the last one to inhale
compressed air. A significantly reduced
procedure-related pain (P = 0.001) for nitrous
oxide could be shown and it proved as effective
as intravenous administered pethidine