ESWL Key Points Overview
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Questions and Answers

What potential complication should be monitored during extracorporeal shock wave lithotripsy?

  • Severe allergic reactions
  • Sudden blood pressure drops
  • Increased respiratory rate
  • Electrocardiogram dysrhythmias (correct)

    • What is a significant drawback of performing anesthesia for ESWL in non-operating room settings?

  • Increased risk of accidents and poor lighting (correct)
  • Potential for better monitoring systems
  • Lower levels of patient anxiety
  • Easier access to the patient

    • Which statement about the shock waves used in ESWL is correct?

  • They are aimed to the patient's abdominal region
  • They are completely painless
  • They require direct surgical intervention
  • They can cause pain during the procedure (correct)

    • Which of the following is a potential risk for patients undergoing ESWL?

    <p>Bacteremia in susceptible patients</p> Signup and view all the answers

    When considering extracorporeal shock wave lithotripsy, what timing aspect is crucial for treatment effectiveness?

    <p>Timing of shock waves relative to ECG monitoring</p> Signup and view all the answers

    What is the typical male to female ratio for nephrolithiasis prevalence?

    <p>3:1</p> Signup and view all the answers

    Which of the following factors is NOT associated with kidney stone formation?

    <p>Age of the patient</p> Signup and view all the answers

    What percentage of kidney stones are primarily composed of calcium oxalate?

    <p>80%</p> Signup and view all the answers

    Which diagnostic tool is specifically used for assessing kidney stones in the urinary tract?

    <p>KUB abdominal x-ray</p> Signup and view all the answers

    Which disorder is associated with frequent episodes of nephrolithiasis?

    <p>Renal tubular acidosis</p> Signup and view all the answers

    What is the estimated percentage of adults in the United States who will develop kidney stones?

    <p>10% to 15%</p> Signup and view all the answers

    When will most kidney stones pass spontaneously without surgical intervention?

    <p>Less than 4 mm in diameter</p> Signup and view all the answers

    Which of the following minerals is NOT commonly associated with the composition of kidney stones?

    <p>Magnesium</p> Signup and view all the answers

    What condition is characterized by the presence of calculi in the kidneys or urinary tract?

    <p>Nephrolithiasis</p> Signup and view all the answers

    In which geographic region of the United States is nephrolithiasis most prevalent?

    <p>Southeast</p> Signup and view all the answers

    What primary mechanism allows shock waves to disintegrate kidney stones without damaging surrounding tissues during ESWL?

    <p>The shock waves shear the stone due to acoustic density matching with water.</p> Signup and view all the answers

    Which aspect of patient care is emphasized during the positioning for ESWL to prevent complications?

    <p>Frequent visual inspection and padding to prevent nerve injury.</p> Signup and view all the answers

    What is the purpose of placing a temporary ureteral stent following ESWL?

    <p>To maintain urinary flow and ureteral patency.</p> Signup and view all the answers

    What advancement in ESWL technology eliminated the need for full body immersion in water during the procedure?

    <p>Development of high-intensity, focused acoustic pulses.</p> Signup and view all the answers

    What is the estimated overall complication rate associated with ESWL?

    <p>5% to 15%</p> Signup and view all the answers

    Which precaution is typically taken to protect the patient’s ears during the ESWL procedure?

    <p>Covering the ears to avoid acoustic trauma.</p> Signup and view all the answers

    How are kidney stones visualized during the ESWL procedure?

    <p>Via fluoroscopy or ultrasound.</p> Signup and view all the answers

    What is a significant consideration when carrying out ESWL treatment in non-operating room settings?

    <p>Availability of anesthesia and emergency equipment.</p> Signup and view all the answers

    What prior method of ESWL required significant changes to accommodate advancements in the technology?

    <p>Full body immersion in water for the procedure.</p> Signup and view all the answers

    During the ESWL procedure, which of the following is critical for ensuring the safety of the patient?

    <p>Positioning to align the stone with the shock wave generator.</p> Signup and view all the answers

    Which anesthetic technique is NOT typically used during an ESWL procedure?

    <p>Bilateral transversus abdominis plane block</p> Signup and view all the answers

    What is a major anesthetic concern for a patient with a history of hypertension undergoing ESWL?

    <p>Potential myocardial ischemia due to sympathetic activation</p> Signup and view all the answers

    Why is a T6 dermatome sensory blockade desirable for neuraxial anesthesia in ESWL?

    <p>It adequately covers the renal innervation areas.</p> Signup and view all the answers

    How does obesity complicate the anesthetic management for ESWL?

    <p>It makes positioning over the shock wave generator more difficult.</p> Signup and view all the answers

    What patient condition is particularly concerning for anesthetic management during ESWL due to possible cardiovascular effects?

    <p>Coronary artery disease post-surgery</p> Signup and view all the answers

    Which anesthetic medication should a patient continue during the perioperative phase for ESWL?

    <p>Metoprolol</p> Signup and view all the answers

    What is the expected outcome of excessive pain during the ESWL procedure?

    <p>Increased myocardial oxygen demand</p> Signup and view all the answers

    Which anesthetic management technique can lead to airway obstruction in obese patients during ESWL?

    <p>Intravenous sedation</p> Signup and view all the answers

    Which anesthetic consideration is least relevant for a patient undergoing ESWL?

    <p>The ambient temperature of the operating room</p> Signup and view all the answers

    What is the primary goal of using local anesthesia or spinal block during ESWL?

    <p>To ensure adequate pain control during the procedure</p> Signup and view all the answers

    What is the timing relevant to the discharge of energy in gated ESWL related to the R wave?

    <p>Discharged 20 milliseconds after the R wave</p> Signup and view all the answers

    Which of the following is a consequence of applying a supramaximal stimulus during the absolute refractory period?

    <p>It reduces the potential for dysrhythmia formation</p> Signup and view all the answers

    How does spontaneous ventilation affect stone movement during ESWL compared to positive pressure ventilation?

    <p>Stone movement is more profound with spontaneous ventilation</p> Signup and view all the answers

    What distance is recommended for focusing the shock wave generator away from a cardiac device during ESWL?

    <p>Greater than 15 cm</p> Signup and view all the answers

    What is the typical duration for which hematuria might occur after undergoing ESWL?

    <p>Approximately 24 to 48 hours</p> Signup and view all the answers

    What role does a magnet play for patients with an automatic internal cardiac defibrillator (AICD) before ESWL?

    <p>It temporarily inhibits the detection of tachyarrhythmias</p> Signup and view all the answers

    What complications may arise due to changes in stone location during positive pressure ventilation?

    <p>Longer ESWL treatment duration with more required shocks</p> Signup and view all the answers

    What patient condition is particularly concerning during ESWL due to potential cardiovascular effects?

    <p>Chronic hypertension</p> Signup and view all the answers

    During which phase of the cardiac cycle is ventricular depolarization marked by the R wave?

    <p>Ventricular systole</p> Signup and view all the answers

    How might tissue damage occur during the ESWL procedure despite focused shock waves?

    <p>As a result of the intensity and time of shock waves affecting nearby tissues</p> Signup and view all the answers

    Study Notes

    ESWL: Key Points

    • During ESWL procedures, careful monitoring of the electrocardiogram (ECG) is crucial to detect potential dysrhythmias like ventricular tachycardia, which can be triggered by the timing of the extracorporeal shock waves.
    • The shock waves used in ESWL are directed towards the patient's flank area and can cause pain.
    • ESWL procedures often occur outside of the operating room, potentially leading to challenges like poor lighting, limited space, high noise levels, and increased safety risks, such as radiation exposure.
    • Despite its noninvasive nature, ESWL can trigger bacteremia in patients who are susceptible to infection.

    Kidney Stones

    • Hardened crystalline masses found in the kidney or ureter
    • Can cause hydronephrosis (swelling of the kidney)
    • More common in men (3:1 ratio) and less common in Asians and African Americans
    • Estimated 10-15% of US adults will develop kidney stones
    • Highest incidence in the southeastern region of the US.
    • Caused by factors including:
      • Diet
      • Mineral content of drinking water
      • Fluoride concentration in drinking water
    • May be associated with metabolic disorders:
      • Renal tubular acidosis
      • Dent disease
      • Hyperparathyroidism
      • Medullary sponge kidney
    • Calcium excretion rate and urine pH influence stone composition
    • Composition of stones includes:
      • Calcium oxalate (80%)
      • Uric acid
      • Calcium phosphate
      • Cystine
      • Struvite
    • Stone composition analysis useful for preventing future stone formation

    Signs and Symptoms

    • Flank pain
    • Nausea and vomiting
    • Hematuria (blood in the urine)
    • Dysuria (painful urination)
    • Frequency
    • Urgency

    Diagnosis

    • Based on signs and symptoms
    • Imaging tests including:
      • KUB abdominal x-ray
      • Intravenous pyelogram
      • Computed tomography (CT) scan
    • Blood tests:
      • Increased white blood cells
      • Hypercalcemia (high calcium levels)
      • Elevated BUN/creatinine (kidney function indicators)
    • Urinalysis:
      • Red blood cells
      • Bacteria
      • Protein
      • Casts
      • Crystalline formations
      • Urine culture

    Treatment

    • Stones less than 4 mm in diameter typically pass on their own
    • Stones greater than 6 mm may require surgical intervention

    Extracorporeal Shock Wave Lithotripsy (ESWL)

    • Purpose: ESWL is a non-invasive procedure used to break down stones in the urinary tract and renal pelvis.

    • Mechanism: ESWL uses focused, high-intensity acoustic pulses emitted from a shock wave generator, which is positioned on the patient's skin near the kidney, to break up the stone.

    • Procedure:

      • The kidney stone is visualized using fluoroscopy or ultrasound.
      • Thousands of shock waves are directed at the stone, breaking it into smaller fragments.
      • These fragments can then pass through the urinary tract and be eliminated.

    • Patient safety:

      • The patient is secured to the ESWL table and padding is used to prevent nerve injury.
      • Ear protection is required due to the loud noise produced by the shock wave generator.
      • A ureteral stent may be placed to maintain urinary flow.

    • Complications: The overall complication rate of ESWL is approximately 5% to 15%.

    • Key facts:

      • The shock waves are designed to target stones without damaging surrounding tissue.
      • Advancements in ESWL technology have eliminated the need for full body immersion in water.
      • Adequate anesthesia and emergency equipment are essential for procedures conducted outside of a hospital setting.

    Anesthetic Options for ESWL

    • General anesthesia: Used for the procedure.
    • Intravenous sedation:
      • Monitored anesthesia care using propofol or remifentanil infusion.
      • Subcutaneous infiltration of local anesthesia.
      • Topical anesthesia using EMLA cream.
      • Unilateral transversus abdominis plane block.
    • Neuraxial anesthesia:
      • Spinal or epidural anesthesia.
      • T6 dermatome sensory blockade is desirable for renal innervation.
      • Spinal block can be performed using local anesthesia and/or sufentanil.
    • Hypertension, hyperlipidemia, and CABG:
      • ESWL can be painful, causing sympathetic nervous system activation.
      • This can lead to cardiovascular responses like tachycardia, increased myocardial contractility, and vasoconstriction.
      • These responses can increase myocardial oxygen demand, potentially leading to ischemia and infarction in patients with cardiac risk factors.
      • The patient's medication regimen should be continued throughout the perioperative phase.
    • Obesity:
      • Positioning for ESWL may be difficult.
      • Obesity can increase the risk of airway obstruction during intravenous sedation.
      • Avoiding dysphoria and agitation is important during the procedure.

    ESWL - Cardiac Considerations

    • Shock waves can cause cardiac dysrhythmias.
    • Gated ESWL delivers energy 20 milliseconds after the R wave in the cardiac cycle.
    • This timing coincides with the absolute refractory period, minimizing dysrhythmia risk.
    • Patients with pacemakers or AICDs require careful monitoring for heart rate and rhythm abnormalities.
    • A magnet should be readily available to reprogram pacemakers if necessary.
    • Place the shock wave generator at least 15 cm away from the cardiac device.

    ### ESWL - Ventilation Impact

    • Spontaneous ventilation promotes stone movement due to diaphragmatic contraction and relaxation during breathing.
    • Positive pressure ventilation can decrease and control stone movement by adjusting tidal volume, respiratory rate, and peak inspiratory pressures.
    • Changes in calculus position due to ventilation can lengthen treatment time and increase the number of shocks required.
    • This increases the risk of complications like bleeding and bruising.

    ### ESWL - Hematuria

    • Hematuria after ESWL is caused by tissue damage in the urinary tract or renal parenchyma from shock wave exposure.
    • Hematuria typically lasts for 24-48 hours post-treatment.

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    Description

    This quiz focuses on the key points regarding Extracorporeal Shock Wave Lithotripsy (ESWL). It covers essential aspects like ECG monitoring, procedural challenges, and potential risks involved in the treatment. Test your knowledge on the important considerations when performing ESWL.

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