EDAIC Hepatic, Renal and Endocrine Anesthesia 2 — Questions and Answers
Question 1: Which neuromuscular blocking agent is preferred in a patient with end-stage renal disease to avoid accumulation of active metabolites?
- Vecuronium
- Rocuronium
- Atracurium (Correct answer)
- Pancuronium
Correct answer: Atracurium
Atracurium undergoes Hofmann elimination and ester hydrolysis independent of organ function, making it the preferred NMBA in renal failure to avoid accumulation.
Question 2: In a patient with chronic kidney disease (CKD stage 5), which opioid is safest to use due to lack of active renally-cleared metabolites?
- Morphine
- Codeine
- Fentanyl (Correct answer)
- Hydromorphone
Correct answer: Fentanyl
Fentanyl is metabolized to inactive norfentanyl and is not significantly renally excreted, making it preferred over morphine (active M6G accumulates) in renal failure.
Question 3: Hyperkalemia in a renal failure patient undergoing anesthesia is a contraindication to which drug?
- Rocuronium
- Succinylcholine (Correct answer)
- Neostigmine
- Midazolam
Correct answer: Succinylcholine
Succinylcholine causes a transient rise in serum potassium of ~0.5 mEq/L, which can precipitate life-threatening cardiac arrhythmias in already hyperkalemic renal failure patients.
Question 4: Which regional anesthesia consideration is most important when planning a brachial plexus block for AV fistula creation in a CKD patient?
- Avoid all regional techniques due to bleeding risk
- Use axillary approach to avoid phrenic nerve block
- Limit local anesthetic dose because of altered protein binding increasing free drug (Correct answer)
- Use chloroprocaine only
Correct answer: Limit local anesthetic dose because of altered protein binding increasing free drug
Hypoalbuminemia in CKD increases the free fraction of amide local anesthetics, raising the risk of systemic toxicity at standard doses.
Question 5: Anemia in chronic renal failure is primarily caused by:
- Iron deficiency from dietary restriction
- Decreased erythropoietin production by damaged kidneys (Correct answer)
- Bone marrow suppression from uremic toxins alone
- Folate deficiency from dialysis
Correct answer: Decreased erythropoietin production by damaged kidneys
The kidneys produce erythropoietin in response to hypoxia; in CKD, reduced erythropoietin synthesis leads to normochromic normocytic anemia.
Question 6: What is the primary concern when administering NSAIDs for postoperative analgesia in patients with pre-existing renal insufficiency?
- Platelet inhibition increasing surgical bleeding
- Inhibition of prostaglandin-mediated afferent arteriolar dilation causing acute kidney injury (Correct answer)
- Drug-drug interaction with tacrolimus
- Increased risk of peptic ulcer only
Correct answer: Inhibition of prostaglandin-mediated afferent arteriolar dilation causing acute kidney injury
In renal insufficiency, the kidney relies on prostaglandins to maintain afferent arteriolar tone; NSAIDs block this compensatory mechanism and can precipitate acute kidney injury.
EDAIC Hepatic, Renal and Endocrine Anesthesia 2
Which neuromuscular blocking agent is preferred in a patient with end-stage renal disease to avoid accumulation of active metabolites?