URETEROLITHIASIS

Definition:
stone (due to deposition of uric salts,
oxalate, or calcium) obstruction
ureteric duct
Stones can form in kidneys or pielum
Stones cant pass the bladder ureter
clog colic

 Etiology
- Kidney stones
- Congenital abnormalities
- Diverticula
1. Supersaturasi existence of stone-forming
substances
2. The factors that led to the crystallization of
the substance
3. There is a substance that causes crystals
gathered into one.

 Clinical Manifestations
Strong contraction and pain colic
Spread front of the abdomen, lower
abdomen, groin area, and up to the genetalia
Pain during urination or frequent urination
stones of distal ureter
<5mm can come out spontaneously

 Diagnostic Tools
- BNO radio-opaque stones only
- IVP selected examination
- USG
- MRI
- Laboratory:
urine sediment examination, urine culture
examination, renal physiology, electrolyte
levels

 Therapy
1. Conservatives
2. Extracorporeal Shock Wave Lithotripsy
(ESWL)
3. Ureteroskopi (URS)
4. Open surgery

ANESTHETIC IN PATIENTS
WITH KIDNEY DISEASE
Retention Na >> extracellular fluid
easily got CHF and pulmonary edema
Autonomic neuropathy slowing gastric
emptying in CRF patients occurrence of
aspiration in perioperative
Renal function lab

 Renal impairment
Dysfunction of glomerular, tubular function or
urinary tract obstruction
BUN
50mg/dl renal impairment
Serum creatinine
a product of muscle metabolism without enzyme
converted kekreatinin.
20-25 mg / kg in men and 15-20 mg / kg in
females.

 BUN: creatinine ratio

BUN: creatinine ratio > 15:1 in lower
volume and edema with disorders related to
reduced tubular flow (such as heart failure,
cirrhosis, nephrotic syndrome) , obstruction
uropathy, increased protein catabolism
Creatinin Clearance
the most acurate method to assess renal
function. Mild: 40-60 mL / min, Moderate :
25-40 mL/min, kidney failure : <25mL/min

 URINALYSIS
the most common test performed for the
evaluation of renal function.
pH, specific gravity (BJ), and glucose quantity
detection, protein, bilirubin, and microscopic
examination of the urine sediment

 Changed of Renal Function and Effect to

Anesthetics Agents
1. Propofol and Etomidate
no signifficant effect. Decrease in protein binding
of etomidate (patient with hipoalbuminemia)
accelerate the effects of pharmacological effects
2. Barbiturates
increased sensitivity to barbiturates ,its caused by
increased circulating free because decrease of
bonding with protein

3. Ketamine
Changed slightly due to kidney disease.
Hypertension secondary to the effects of
ketamine could not desirable in patients with
renal hypertension
4. Benzodiazepines
Potential accumulation of the active metabolite

5. Opioids
-Accumulation of morphine (morphine-6glucuronide) and meperidine metabolites
prolong respiratory depression have been
reported in some patients with renal failure.
- Increased levels of normeperidine,
metabolitmeperidine, associated with seizures.
-frequently used opioid agonist-antagonists
(nalbuphine butorphanol and buprenorphine)
not affected by renal failure.

Anticholinergic Agents
In a premedication dose atropine and
glycopyrolate usually safe in renal impairment
patient.

 Inhalation Agents
Volatile agents
Volatile anesthetic agents is almost ideal for
patients with dysfunction renal not
dependent on renal elimination
NO
Many clinicians do not use or limit the use of
NO2 by 50% in patients with renal failure in
the goal to increase the use of O2artery on the
state of anemia.

 Muscle Paralytic
Succinyl choline
SC can be used safely in renal failure
Cisatracurium, atracurium & Mivacurium
Mivacurium dependent on renal elimination is
minimal. Cisatracurium & atracurium elimination
degraded in plasma by enzymatic hydrolysis of
esters and nonenzymatik Hofman. These agents
may be the drug of choice for muscle paralysis in
patients with renal failure.

Vecuronium & Rucoronium

Elimination of vecuronium primarily in
the liver, but >20% elimination in urine.
The effects of large doses is extension
work on severe kidney disease.
Pancuronium, Pipecuronium,
Alcuronium, & Doxacurium
These medications primarily dependent
on renal excretion (60-90%). Should be
closely monitored when these drugs are
used in abnormal kidney function.

Metocurine, Gallamine & Decamethonium

These drugs are almost entirely dependent on
renal excretion for elimination and its use
should be avoided in patients with impaired
renal function.
Reversal Medications
Renal excretion is the primary route of
elimination for Tensilon, neostigmine and
pyridostigmine. The half-life of these drugs in
patients with impaired renal function is extent.

ACUTE RENAL FAILURE

rapid decline in kidney function resulting in
the build up of waste nitrogen (azotemia).
CHRONIC RENAL FAILURE
characterized by a progressive decline in
renal function and the irreversible within 3-6
months. GFR decreased < 25 mL / min.

Manifestations of Renal Failure

a. Metabolic
b.Hematologic
c. Cardiovascular
d.Pulmonary
e. Endocrine
f. Gastrointestinal
g.Neurology

Preoperative Evaluation
- Evaluation of azotemia
- Physical
- Laboratory
- Signs of fluid overload or hypovolemia
- Blood gas analysis
- Thorax rontgen
- EKG
- Echho
- Anemia transfusion

Muscle relaxants
Metocurine, Gallamine, Decamethonium, pancuronium,
Pipecurium, Doxacurium, Alcuronium
Anticholinergics
Atropine, Glycopyrrolate
Metoclopramide
H2reseptor antagonists
Cimetidine, ranitidine
DigitalisDiuretics

Calcium channel antagonists

Nifedipine, Diltiazem
Adrenergic beta blockers
Propranolol, Nadolol, pindolol, Atenolol
Anti Hipertensives
Clonidine, methyldopa, Captporil, Enalapril, lisinopril,
hydralazine nitroprusside (thiocyanate)
Antiarrhytmics
Procainamide, Disopyramide, Bretylium, Tocainide,
Encainide (genetically determined)
Bronchodilators
Terbutalline

Psychiatric
Lithium
Antibiotics
Penicillins, Cephalosporins, aminoglycosides,
Tetracycline, Vancomycin
Anticonvulsants
Carbamazepine, ethosuximide, primidone

PREMEDICATION
- Stable and conscious patirnts reduction of
the dose opioid or benzodiazepines.
- Promethazin 12.5-25 mg intramuscular
sedation and anti emetic.
- aspiration prophylaxis H2 blocker
( indicated in patients nausea, vomiting or
gastrointestinal bleeding). Ex.Metoclopramide,
10 mg orally or slow IV drip
- should be continued anti-hypertension

INTRAOPERATIVE
- Monitoring
overall medical condition
danger of the occlusion blood pressure
indicated in patients with uncontrolled
hypertension
Aggressive invasive monitoring diabetic
with severe renal disease who are undergoing
major surgery(high morbidity 10 x more in
diabetic patients without kidney disease)

- Induction
Patients with nausea, vomiting or gastrointestinal
bleeding should undergo irapid induction with cricoid
pressure.
Thiopental 2-3 mg / kg or propofol 1-2 mg / kg ( often
used). Etomidate ,0,2-0, 4 mg / kg in patients with no
hemodynamic stabil.
Opioid, beta-blockers (esmolol), or lidocaine reduce
hypertension renponse from the intubation
Succinylcholine, 1.5 mg / kg, can be used to
intubasiendotrakeal if blood potassium levels 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) can
be used for intubated patients with hyperkalemia.
Vecuronium, 0.1 mg / kg alternative, but its effects must
be considered.

- Maintenance
Control hypertension with minimal effects on
cardiac output, due to an increase in cardiac output is a
mechanism of compensation principle in anemia.
Volatile anesthetics, nitrous oxide, fentanyl,
sufentanil, alfentanil, and morphine satisfactory
maintenance agent.
Isoflurane and desflurane are volatile substances
choice because they have minimal effect on cardiac
output.
Nitrous oxide : cautiously
Meperidine not a good choice
Morphine may be used
Ventilation controlled safest method in patients with
renal failure.

- Fluid Therapy
Superficial surgery require fluid
replacement with 5% dextrose in water.
RL should be avoided in patients with
hyperkalemia who require a lot of fluids,
because the content of potassium (4 meq / L)
Blood loss :PRC