UROLOGIC ANESTHESIA/RENAL DISEASE
| USE OF LOCAL ANESTHETICS FOR UROLOGIC ANESTHESIA —John E. Tetzlaff, MD, Professor of Anesthesiology,
Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, and Vice Chair, Center for Anesthesiology
Education, Division of Anesthesiology, Critical Care Medicine, and Comprehensive Pain Management, Cleveland
Clinic, Cleveland, OH
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| Local anesthetic pharmacology: amphipathic molecule (tertiary amine water-soluble; other side of molecule lipid-soluble);
weak base (manufactured in acid state [pH 5.0-5.5]; ionized in cationic form); blocking of intraneural sodium channel
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| Action of local anesthetics: extracellular injection (avoid disrupting nerve cell membrane); neural membrane passage;
potency of local anesthetic directly proportional to lipid solubility; onset inversely proportional to pKa; duration related
to lipid solubility and protein binding; toxicity directly proportional to potency
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| Circumcision and penile surgery: simple interventions make extraordinary difference; 2% lidocaine gel decreases
postoperative pain behavior in infants by ≤50%; if properly applied (avoid excessive amounts), eutectic mixture of local anesthetic
(EMLA) decreases pain associated with circumcision to “near zero”; advanced planning or patience required; if using
EMLA cream for intraoperative phase of neonatal circumcision, necessary to apply it to foreskin with slightly compressive
and minimum-contact dressing for 30 to 45 min before procedure; with application of EMLA cream, acute pain behavior reduced
during procedure and for ≤24 hr thereafter; also, neonatal behavior “substantially better” than if neonate has circumcision
with no analgesia; classic penile block should be performed by someone who has developed “touch for just passing
through the connective tissue”; dorsal penile block one of easiest regional anesthesia techniques; construct horizontal line in
subcutaneous (SC) tissue to form wheal slightly wider than base of penis (gives ≈80% anesthesia); Broadman showed SC infiltration
at base of penis associated with superb improvement in early neonatal behavior; study of caudal block vs penile
block vs systemic opioids for hypospadias repair shows caudal block achieves best pain control, probably because bupivacaine
in caudal space lasts longer than in highly vascular SC tissue; pain control not as long lasting with caudal block for inguinal
surgery as for penile surgery
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| Cystoscopy: long history with local anesthetics; cocaine first solution used, but toxic (induced hypertension, tachycardia,
seizure activity, and induction of myocardial ischemia); procaine poor topical anesthetic and toxic at doses needed (but
“maybe not as much myocardial ischemia”); lidocaine “probably the best of all the [choices]”; urologists particularly
good at getting gel-based lidocaine through urethra and prostate and into neck of bladder; tetracaine had short “honeymoon”
with urology; however, in unmonitored low-light settings (eg, lower gastrointestinal [GI] endoscopy), some patients
became morbid and died; report that equal mixture of 4% cocaine and 1% lidocaine provides excellent analgesia;
however, no different from 0.5% lidocaine alone and toxicity greater
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| Dialysis: report of small number of patients who were needle-phobic; EMLA provided to site of shunt 45 min before cannulation
of arteriovenous (AV) fistula results in complete analgesia
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| Extracorporeal shock wave lithotripsy (ESWL): previously required “fair amount” of anesthesia; over years, technology
has changed significantly; early on, submersion of chest in patient with T8 spinal level occasionally resulted in difficulty
tolerating sense of respiratory insufficiency; sufentanil applied via epidural equivalent to lidocaine in low-voltage ESWL
environment; local anesthetic in epidural space results in slower recovery of motor function than with opioid alone; intercostal
blocks (using 0.25% bupivacaine) provide excellent pain control and earlier ambulation (no motor block required); epidural
technique excellent option for spinal anesthesia, but may be less successful in multiple repeat procedures; likely related to distortion
or scarring in epidural space (ie, less likely to distend); in low-voltage lithotripter, EMLA has same potential advantages;
can be used as sole anesthetic or as means of minimizing other anesthesia; all reports indicate necessity of application
well in advance of procedure; duration of action, 2.5 to 3.0 hr; patient hyperalgesic during first 30 min after application; potential
opiate-sparing properties something to consider in patient with refractory nausea
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| Nephrectomy: extremely painful procedure; patient undergoing open procedure requires profound analgesia; patient-
controlled analgesia (PCA) inadequate for open procedure (at least during first 24 hr); epidural advantageous for early
ambulation; Ecoffey demonstrated excellent pain control with epidural, with no difference between thoracic and lumbar
epidural catheter; subsequent reports indicate effectiveness of low-dose local anesthesia, with low-dose opioid delivered
directly within dermatome
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| Orchiopexy: caudal anesthesia effective in study of inguinal vs penile surgery; study of caudal block and ilioinguinal/iliohypogastric
block found that 2 SC injections at 45° to superior end of inguinal incision (arrowhead shape) reduce sensation
postoperatively by ≥80%; other procedure, which involves leaving inguinal canal wound open, pouring 0.25%
bupivacaine into wound after fascia closed, and letting it “sit there for 5 min,” results in “superb” supplement to ilioinguinal/iliohypogastric
block; can be performed by senior surgeon, fellow, junior resident, or fourth-year medical student
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| Pheochromocytoma: regional anesthesia usually not considered; optimal use of α-blockers (and sometimes α-blockers
and β-blockers) preoperatively by endocrinologists has made some procedures “blasé”; thoracic epidural can be excellent
adjunct to general anesthesia to block stimuli that lead to massive surges of catecholamine; intravenous (IV) lidocaine effective
in suppressing effect of released catecholamines (minimizes impact); suggestion that preemptive administration
of lidocaine decreases response of adrenal gland (study has not been repeated)
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| Transurethral resection of prostate (TURP): previously thought that TURP syndrome best detected by talking to
patient (therefore “an awake patient is the way to go”); less relevant with newer techniques; easier to control environment
when patient under general anesthesia; likely to detect rupture or tear of bladder neck during new- or old-style TURP;
awake patient aware of irrigating fluids streaming into abdomen (due to peritoneal irritation); epidural acceptable as alternative
to spinal but seems like overkill (more involved technical procedure; higher failure rate; creates lower motor block
[not relevant in TURP]); postoperative pain after TURP relatively minimal, therefore no need to place epidural; administration
of dilute bupivacaine with dilute lidocaine into bladder provides rapid onset and relatively long duration of pain
relief
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| Radical prostatectomy: epidural provides excellent analgesia, leads to early return of bowel function, and decreases hospital
stay
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| Vasectomy: EMLA administered 45 min before procedure eliminates pain of injection for deeper anesthetic
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| CARING FOR THE PATIENT WITH END-STAGE RENAL DISEASE (ESRD)—Mark Stafford-Smith, MD, Professor of
Anesthesiology, Director, Fellowship Education, and Director, Cardiothoracic Anesthesia and Critical Care Medicine Fellowship,
Duke University School of Medicine, Durham, NC
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| Introduction: creatinine used as clinical tool to determine renal filtration function (surrogate for measuring filtration occurring
in kidneys); when both kidneys fully functioning, glomerular filtration rate (GFR) ≈120 mL/min (creatinine relatively
insensitive to large changes; doubling of creatinine reflects one-half of filtration function); loss of one kidney and subsequent
creatinine clearance of 60 mL/min defined as chronic kidney disease; uremic symptoms begin with only one-quarter
kidney function (typically, dialysis instituted at this point); kidney generally associated with filtration function, but also responsible
for other functions (eg, regulation of water balance and of acids, bases, and electrolytes, hormone release [eg,
erythropoietin], regulation of blood count in circulation, clearance of waste); in United States, ≈400,000 patients currently
on long-term dialysis
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| Surgical risk: study of >2000 patients with ESRD having operative procedures (majority for vascular access) found high
degree of perioperative morbidity and mortality; most common causes of mortality include arrhythmia and sepsis; risk increases
with emergency procedure, diabetes, and advanced age; morbidity also more frequent (longer stay in intensive care
unit [ICU] and hospital); common problems include postoperative infectious complications, hemodynamic instability and
decreased circulation, and secondary complications of ESRD
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| Limitations of dialysis: only partially replaces kidney function; with peritoneal dialysis, even clearance of small molecules
(eg, urea) limited (“we’re not far off the threshold for uremia”); with larger molecules, dialysis itself becomes less
and less efficient at removing substances from circulation; molecules that are protein-bound “clearly harder to get off”
(due to equilibrium); nephrologists “steer” dialysis primarily by low molecular weight small molecules; dialysis adequate
if creatinine values and urea values in acceptable range; residual molecules (uremic toxins) inadequately cleared by dialysis
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 | Significant cardiovascular risk: elevated frequency of cerebrovascular disease, coronary artery disease, and peripheral
vascular disease; GI dysfunction (including reflux) may cause chest pain, and differentiation may be difficult; neurologic
dysfunction may eliminate chest pain (even with ischemia); algorithm for preoperative cardiac risk in noncardiac
surgery—with good exercise tolerance, proceed with surgery; if concerns exist, consider noninvasive testing and
preoperative treatment with atenolol or other β- blocker; uremic toxin known as asymmetric dimethylarginine accumulates
as kidney function decreases; study of ESRD found prolonged effect of asymmetric dimethylarginine on increased
mortality; inhibits nitric oxide synthase (arterial stiffness may be partially attributable to this inhibition);
results in decreased diastolic flow
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| Management of hematocrit: recombinant human erythropoietin prescribed for most patients with ESRD, due to inability
of kidneys to produce erythropoietin in response to anemia; other factors leading to decreased hematocrit include dialysis
(decreased iron stores), increased blood loss, and increased fragility of red blood cells (RBCs); leads to hematocrit
of 25% to 28%; also attributed to increased myocardial hypertrophy; treatment with recombinant erythropoietin leads
to increased hematocrit, reduced myocardial hypertrophy, and overall patient improvement; meta-analysis of ≈900 patients
given erythropoietin preoperatively, with or without autologous predonation, for hip surgery; compared to placebo,
patients more likely to avoid transfusion; second meta-analysis found significant advantages, including
regression of ventricular hypertrophy, avoidance of transfusion, better cognitive function, and better quality of life;
however, in chronic kidney disease patients as well as ESRD patients, trend toward increased mortality in those receiving
higher target hematocrit; greater difference in cardiovascular events; increased thrombosis of vascular access grafts
also seen; 2 issues balanced with target hematocrit of 33% to 36% (11-12 g/dL of hemoglobin); target ≤39%
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| Timing of preoperative dialysis: previously, many more patients presented with pericardial effusion and tamponade (less
frequent now, due to dialysis); when considering water balance, in addition to intake and output, “we obviously have to
think about dialysis”; Foley catheter may be useful in perioperative period to measure output; volume overload potentially
associated with congestive heart failure (also ischemia and high output due to shunt); if possible, avoid adverse
potential consequences of dialysis; dysequilibrium syndrome can occur immediately after dialysis; hypovolemia also
potential problem; if given choice, most physicians have patient undergo dialysis on day before surgery; necessary to
take electrolyte measurement during preoperative holding period, to reconfirm serum potassium
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| Immunity: patient with ESRD at high risk for infections; majority of infections due to Staphylococcus aureus; patients not
only at risk because immunity suppressed by uremic toxins, but also because patients often malnourished; chronic inflammatory
state partly due to exposure to circulatory tubing of dialysis; shunt infections most common, but pneumonia and
sepsis most common serious infections; meticulous asepsis crucial; requires preoperative prophylaxis
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| Hyperkalemia/acidosis: approximately one-third of patients presenting for surgery hyperkalemic; risk factors include potential
for blood transfusion, acidosis, angiotensin-converting enzyme (ACE) inhibitors, and β-blockers; consider use
of normal saline, rather than lactated Ringer’s solution; perioperative goal to begin with potassium <5.5 mEq/L; consider
arterial line despite challenge with vascular access; attentiveness to ventilatory management important; metabolic
acidosis typical of patient with ESRD; compensate with mild respiratory alkalosis
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| Coagulopathy of ESRD: ≈50% of ESRD patients who receive blood hyperkalemic (partially due to storage lesion of
blood [potassium and lactate gradually leak from stored RBCs]); wash RBCs before infusion (reduces potassium and
lactate); treat potassium problems by avoiding inciting agents (eg, succinylcholine), giving IV calcium, hyperventilating
to PCO2 of 30 mm Hg, giving sodium bicarbonate, giving insulin and glucose (if monitoring glucose), and considering
intervening with prophylactic or emergency dialysis; coagulopathy involves platelet problem; prothrombin time
(PT), partial thromboplastin time (PTT) and platelet counts normal, but bleeding time prolonged; multifactorial uremic
toxin has major effect on platelets; does not improve with platelet transfusion; treat by increasing von Willebrand and
factor VIII levels, giving desmopressin (1-deamino-8-D-arginine vasopressin [DDAVP]), 3 µg/kg over 30 min (effective
only if repeated q12h), cryoprecipitate, and estrogen conjugates 1 wk before; increasing hematocrit improves coagulopathy;
dialysis helps clear uremic toxins
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| Variations in drug management: consider role of renal clearance; consider changes in unbound fraction of drug with
changes seen in ESRD; patient on peritoneal dialysis has problem with protein-losing characteristics; best to avoid
drugs totally dependent on renal clearance; loading dose unaltered, but maintenance dose drastically reduced; frequently
used drugs include antibiotics (eg, penicillin, cephalosporin), older muscle relaxants, and digoxin; many drugs
partially dependent on renal clearance; loading dose unaltered, but maintenance dose decreased significantly; includes
anticholinergics (eg, atropine, glycopyrrolate), reversal agents (eg, neostigmine, edrophonium), muscle relaxants (eg,
vecuronium, pancuronium), cardiovascular drugs (eg, milrinone), and some barbiturates; titrate effect and decrease
dose of drugs with unbound fraction (eg, thiopental, diazepam); active or toxic metabolites common; suggamadex useful
for reversal of vecuronium, pancuronium, and rocuronium
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| Postoperative concerns: logical approach to restart dialysis and postoperative medications; cardiac monitoring important;
vigilance for infectious complications also important
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Suggested Reading
Anderson GF: Circumcision. Pediatr Ann 18:205, 209, 1989; Blaise G et al: Postoperative pain relief after hypospadias
repair in pediatric patients: regional analgesia versus systemic analgesics. Anesthesiology 65:84, 1986; Broadman L et al:
Post-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penis. Anesthesiology 67:399, 1987;
Cederholm I et al: Sensory, motor, and sympathetic block during epidural analgesia with 0.5% and 0.75% ropivacaine with
and without epinephrine. Reg Anesth 19:18, 1994; Durmaz I et al: Prophylactic dialysis in patients with renal dysfunction
undergoing on-pump coronary artery bypass surgery. Ann Thorac Surg 75:859, 2003; Eaton MP et al: Subarachnoid sufentanil
versus lidocaine spinal anesthesia for extracorporeal shock wave lithotripsy. Reg Anesth 22:515, 1997; Ecoffey C et al:
Lumbar and thoracic epidural anesthesia for urologic and upper abdominal surgery in infants and children. Anesthesiology
65:87, 1986; Groudine SB et al: Intravenous lidocaine speeds the return of bowel function, decreases postoperative pain,
and shortens hospital stay in patients undergoing radical retropubic prostatectomy. Anesth Analg 86:235, 1998; Hannallah
RS et al: Comparison of caudal and ilioinguinal/iliohypogastric nerve blocks for control of post-orchiopexy pain in pediatric
ambulatory surgery. Anesthesiology 66:832, 1987; Malhotra V et al: Intercostal blocks with local infiltration anesthesia for
extracorporeal shock wave lithotripsy. Anesth Analg 66:85, 1987; Palevsky PM: Perioperative management of patients with
chronic kidney disease or ESRD. Best Pract Res Clin Anaesthesiol 18:129, 2004; Pastan S et al: Dialysis therapy. N Engl J
Med 338:1428, 1998; Petroni KC et al: Continuous renal replacement therapy: anesthetic implications. Anesth Analg
94:1288, 2002; Pliskin MJ et al: Cocaine and lidocaine as topical urethral anesthetics. J Urol 141:1117, 1989; Rickford
JK et al: Comparative evaluation of general, epidural and spinal anaesthesia for extracorporeal shockwave lithotripsy. Ann R
Coll Surg Engl 70:69, 1988; Sladen RN: Anesthetic considerations for the patient with renal failure. Anesthesiol Clin North
America 18:863, 2000; Wehle B et al: Repeated application of EMLA cream 5% for the alleviation of cannulation pain in
haemodialysis. Scand J Urol Nephrol 23:299, 1989.
Educational Objectives
| The goal of this program is to identify local anesthetics used for urologic anesthesia and improve management of end-stage
renal disease (ESRD). After hearing and assimilating this program, the clinician will be better able to:
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| 1. Discuss application of local anesthetics for urologic surgical procedures, including circumcision, cystoscopy, dialysis,
extracorporeal shock wave lithotripsy, nephrectomy, pheochromocytoma, transurethral resection of the prostate, radical
prostatectomy, and vasectomy.
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| 2. Enumerate major risk factors presented by the patient with ESRD.
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| 3. Develop a plan for preoperative preparation and management of the patient with ESRD.
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| 4. Discuss the role of prophylactic dialysis, transfusion, and pharmacologic interventions.
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| 5. Formulate an anesthetic plan for intraoperative and postoperative management of the patient with ESRD.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a
proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgements
Dr. Tetzlaff spoke in Naples, FL, at Survey of Current Issues in Surgical Anesthesia, held November 28 to December 2,
2007, and sponsored by the Cleveland Clinic Foundation, Division of Anesthesiology, Critical Care Medicine, and Comprehensive
Pain Management; Dr. Stafford-Smith spoke in New York, NY, at the 61st Annual Postgraduate Assembly in Anesthesiology,
held December 7-11, 2007, and sponsored by the New York State Society of Anesthesiologists, Inc. The
Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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