24 Update in Anaesthesia

a 45 degree caudad angle (towards the feet) and
slightly posterior angle. The angle of approach is
important to avoid accidental intravascular or
intrathecal injection. The needle is then advanced
carefully until a paraesthesia is elicited. A click
may be detected as the needle passes through the
prevertebral fascia. This usually occurs at the
superficial level. The use of a nerve stimulator with
a special insulated needle is very helpful in
confirming the correct placement of the needle and
performing the interscalene block accurately.
Correct stimulation produces twitching below the
shoulder. Stimulation of the diaphragm indicates
too anterior an approach. Once paraesthesia is
obtained, the needle is stabilised and after negative
aspiration for blood, 20 to 30mls of the local
anaesthetic solution is injected slowly and carefully.
Local anaesthetic solution Bupivacaine 0.375-
0.5% solution may be used safely in the volumes
between 20-40mls, but the maximum dose of 2 mg/
kg should not exceeded. Other local anaesthetic
agents like lignocaine or prilocaine may be used.
Complications
l Inadvertent epidural or subarachnoid injection
is a potentially serious complication resulting
from incorrect needle placement.
l Vertebral artery injection, this can result in
convulsions and loss of consciousness.
l Phrenic nerve block is frequently produced,
this complication precludes bilateral use of
this technique.
l Recurrent laryngeal, vagus, and cervical
sympathetic nerves are sometimes blocked.
l Pneumothorax is rare but can happen with
deep placement of the needle and in unskilled
hands.

PHYSIOLOGY OF THE KIDNEY

Dr. P. Stewart the medulla. These nephrons have a greater
Sydney concentrating ability, the mechanism being
Australia explained below. The kidney is unique as it has two
capillary beds arranged in series, the glomerular
The Functions of the Kidney capillaries which are under high pressure for
l Regulation of the water and electrolyte content filtering, and the peritubular capillaries which are
of the body. situated around the tubule and are at low pressure
l Retention of substances vital to the body (figure 1). This permits large volumes of fluid to be
such as protein and glucose filtered and reabsorbed.
l Maintenance of acid/base balance.
Afferent arteriole Efferent arteriole
l Excretion of waste products, water soluble
toxic substances and drugs. Glomerulus
l Endocrine functions.
Regulation of the water and electrolyte content Bowman's
of the body Capsule Peritubular
The kidney allows a person to eat and drink Capillaries
according to their habits without changing the
composition of their fluid compartments.
Renal Blood Supply is normally is about 20% of
the cardiac output. Approximately 99% of the
blood flow goes to the cortex and 1% to the medulla.
The cortex is the outer part of the kidney containing
most of the nephrons. The medulla is the inner part The Nephron: Each kidney consists of about one
of the kidney and contains the specialised nephrons million nephrons. The nephron is made up of a
in the juxta-medullary region, immediately next to glomerulus and its tubule (figure2). The tubule is
Update in Anaesthesia 25

made up of a number of sections, the proximal autoregulation of renal blood flow and a feedback
tubule, the medullary loop (loop of Henle), and the mechanism known as “ glomerular tubular balance”.
distal tubule which finally empties into the collecting Glomerular Tubular balance. When there is a
duct. decrease in GFR, there is a resulting decrease in the
fluid flow rate within the
Nephron: tubule. At the loop of Henle,
Distal there is greater time for
H2O NaCI Tubule
reabsorption of sodium and
More
Glomerlus
Isotonic
hypotonic
chloride ions. Therefore there
+ +
is a decrease in the number of
K H
Proximal Na +
sodium and chloride ions
Hypotonic
HO 2 Na +
Tubule K +
'Bulk H + reaching the distal tubule which
Reabsorber' is detected by the macula densa.
(C) Collecting
Duct This in turn decreases the
(A) Urea resistance in the afferent
arteriole which results in an
Isotonic

HO 2 increase in renal blood flow. It

+ -
Na CI HO 2
also increases renin release
Hypertonic
Hypertonic from the juxtaglomerular
(B) apparatus which stimulates
Loop of Henle angiotensin II production
causing constriction of the
efferent arteriole.
Urine is formed as a result of a three phase process These both act to increase the hydrostatic pressure
- simple filtration, selective and passive in the glomerular capillary bed and return GFR to
reabsorption and excretion. normal (table 1).
Filtration The juxtaglomerular complex consists of macula
Filtration takes place through the semipermeable densa cells, which are special distal tubular
walls of the glomerular capillaries which are almost epithelial cells which detect chloride concentration
impermeable to proteins and large molecules. The and modified smooth muscle cells, juxtaglomerular
filtrate is thus virtually free of protein and has no cells, in the walls of the afferent and efferent
cellular elements. The glomerular filtrate is formed arteriole. These cells produce renin. Renin is an
by squeezing fluid through the glomerular capillary enzyme which converts the plasma protein
bed. The driving hydrostatic pressure (head of angiotensinogen to angiotensin I. Angiotensin
pressure) is controlled by the afferent and efferent converting enzyme (ACE) which is formed in small
arterioles, and provided by arterial pressure. About Table 1
20% of renal plasma flow is filtered each minute
(125 ml.min-1). This is the glomerular filtration
rate (GFR).
In order to keep the renal blood flow and GFR
relatively constant hydrostatic pressure in the
glomerulus has to be kept fairly constant. When
there is a change in arterial blood pressure, there is
constriction or dilatation of the afferent and efferent
arterioles, the muscular walled vessels leading to
and from each glomerulus. This process is called
autoregulation.
Autoregulation of GFR is achieved by
26 Update in Anaesthesia

quantities in the lungs, proximal tubule and other the substance or interstitium of the medulla. This
tissues, converts angiotensin I to angiotensin II high concentration of solutes is maintained by the
which causes vasoconstriction and an increase in counter current multiplier. A counter current
blood pressure. Angiotensin II also stimulates the multiplier system is an arrangement by which the
adrenal gland to produce aldosterone which causes high medullary interstitial concentration of solute
water and sodium retention which together increase is maintained, giving the kidney the ability to
blood volume. concentrate urine. The loop of Henle is the counter
This is a negative feedback system. In other words current multiplier and the vasa recta is the counter
the initial stimulus is a fall in blood volume which current exchanger, the mechanism being described
leads to a fall in perfusion pressure in the kidneys. below.
When blood volume, renal perfusion and GFR Actions of different parts of the loop of Henle
improve the system feeds back to switch off or turn A The descending loop of Henle is relatively
down the response to the stimulus. impermeable to solute but permeable to
Selective and Passive Reabsorption water so that water moves out by osmosis,
The function of the renal tubule is to reabsorb and the fluid in the tubule becomes hypertonic.
selectively about 99% of the glomerular filtrate. B The thin section of the ascending loop of
The Proximal Tubule reabsorbs 60% of all solute, Henle is virtually impermeable to water, but
which includes 100% of glucose and amino acids, permeable to solute especially sodium and
90% of bicarbonate and 80-90% of inorganic chloride ions. Thus sodium and chloride ions
phosphate and water. move out down the concentration gradient,
Reabsorption is by either active or passive transport. the fluid within the tubule becomes firstly
Active transport requires energy to move solute isotonic then hypotonic as more ions leave.
against an electrochemical or a concentration Urea which was absorbed into the medullary
gradient. It is the main determinant of oxygen interstium from the collecting duct, diffuses
consumption by the kidney. Passive transport is into the ascending limb. This keeps the urea
where reabsorption occurs down an electrochemical, within the interstitium of the medulla where
pressure or concentration gradient. it also has a role in concentrating urine.

Most of the solute reabsorption is active, with water C The thick section of the ascending loop of
being freely permeable and therefore moving by Henle and early distal tubule are virtually
osmosis. When the active reabsorbtion of solute impermeable to water. However sodium and
from the tubule occurs, there is a fall in concentration chloride ions are actively transported out of
and hence osmotic activity within the tubule. Water the tubule, making the tubular fluid very
then moves because of osmotic forces to the area hypotonic.
outside the tubule where the concentration of solutes
is higher.
The Loop of Henle is the
part of the tubule which
dips or “loops” from the 300 350
cortex into the medulla, H2O
600 Solute 300 Medullary
(descending limb), and 600
Solute H2O Solute 600 Interstitium
then returns to the cortex, mosm/l
Solute 800
(ascending limb). It is this 800 H2O Solute 900
part of the tubule where Solute 1200
1000 1000
urine is concentrated if 1200
necessary. This is possible
because of the high
concentration of solute in Vasa Recta
Update in Anaesthesia 27

The Vasa Recta (figure 3) is a portion of the or removal of hydrogen ions results in minimal
peritubular capillary system which enters the change to pH, the purpose of the buffer.
medulla where the solute concentration in the l The pH is the negative log to base 10 of the
interstitium is high. It acts with the loop of Henle hydrogen ion concentration [H+] and indicates
to concentrate the urine by a complex mechanism the acidity of the solution. The more acid the
of counter current exchange. If the vasa recta did solution the higher the H+ concentration but
not exist, the high concentration of solutes in the the lower the pH. The pH in the body is kept
medullary interstitium would be washed out. Solutes under tight control as almost all enzyme
diffuse out of the vessels conducting blood towards activities in the body are dependent on the pH
the cortex and into the vessels descending into the being normal.
medulla while water does the opposite, moving
from the descending vessels to the ascending vessels. The lungs and kidneys work together to produce a
This system allows solutes to recirculate in the normal extracellular fluid and arterial pH of 7.35-
medulla and water, in effect, to bypass it. 7.45 (34-46 nmol.l-1 H+ concentration). Carbon
dioxide (CO ), when dissolved in the blood is an
Distal Tubule and Collecting Duct: The final acid, and is 2excreted by the lungs. The kidney
concentration of urine depends upon the amount of excretes fixed acid and performs three functions to
antidiuretic hormone (ADH) secreted by the achieve this:-
posterior lobe of the pituitary. If ADH is present the
distal tubule and the collecting duct become 1. Tubular secretion of acid (figure 4): The
permeable to water. As the collecting duct passes buffer sodium bicarbonate, is filtered by the
through the medulla with a high solute concentration glomerulus and then reabsorbed in the proximal
in the interstitium, the water moves out of the tubule. The sodium is absorbed by a sodium/
+ + +
lumen of the duct and concentrated urine is formed. hydrogen ion pump (Na /H ) exchanging Na for
+
In the absence of ADH the tubule is minimally H on the luminal proximal border of the tubular
+ +
permeable to water so large quantities of dilute cell. A sodium/potassium pump (Na /K ) forces
urine is formed. Na+ through the cell from tubular fluid in exchange
for potassium.
There is a close link between the hypothalamus of
the brain and the posterior pituitary. There are cells
Bicarbonate Reabsorption:
within the hypothalamus, osmoreceptors, which
are sensitive to changes in osmotic pressure of the Interstial Proximal Tubular
blood. If there is low water intake, there is a rise in Fluid Renal Tubular Cell Urine
osmotic pressure of the blood, and after excess +
Na
intake of water, the reverse. Nerve impulses from K+ CO + H O
2 2
CO + H O
the hypothalamus stimulate the posterior pituitary Na / K ATPase
+ + 2 2

Carbonic Anthydrase
to produce ADH when the osmotic pressure of the (in brush border)
blood rises. As a result water loss in the kidney is CO 2
H CO
reduced because ADH is secreted, and water 2 3

reabsorbed in the collecting duct. +

Acid/Base Function
l Acid: a substance that can release hydrogen
ions in solution.
l Base: a substance that can accept
hydrogen ions in solution.
l Buffer: a substance whose pKa (the pH at a)
which half is in the ionised form and half
unionised) is close to the pH of its
environment. In those circumstances, addition
Na
HCO3 - + H+
H+ Na+/H+
Antiporter
2. Glomerular filtration of buffers which
combine with H+ :
The majority of the filtered bicarbonate is
reabsorbed (90% in the proximal tubule).
The H+, released as the Tubular Secretion of
Acid (above), forms carbonic acid with the
bicarbonate (HCO3-). H+ + HCO3 = H2CO3
28 Update in Anaesthesia

Carbonic anhydrase, found in the proximal Aldosterone promotes sodium ion and water
tubular cells, catalyses the reaction to carbon
reabsorption in the distal tubule and collecting duct
dioxide (CO2) and water (H2O) (figure 4). where Na+ is exchanged for potassium (K+) and
The CO2 diffuses into the cell where it againhydrogen ions by a specific cellular pump.
forms carbonic acid in the presence of Aldosterone is also released when there is a decrease
carbonic anhydrase. The carbonic acid ionisesin serum sodium ion concentration. This can occur,
to H+ and HCO3- . The H+ is then pumped out for example, when there are large losses of gastric
of the cell back to the lumen of the tubule by
juice. Gastric juice contains significant
the Na+/H+ pump (1 above) and the sodium concentrations of sodium, chloride, hydrogen and
is returned to the plasma by the Na+/K+ pump potassium ions. Therefore it is impossible to correct
(1 above). Water is absorbed passively. the resulting alkalosis and hypokalaemia without
b) Other buffers include inorganic phosphate first replacing the sodium ions using 0.9% saline
(HPO4-), urate and creatinine ions which are solutions.
excreted in urine as acid when combined with Atrial Natruretic Peptide(ANP) is released when
H+ ions secreted in the distal nephron atrial pressure is increased e.g. in heart failure or
3. Ammonia is produced enzymatically from fluid overload. It promotes loss of sodium and
glutamine and other amino acids, and is chloride ions and water chiefly by increasing GFR.
secreted in the tubules. Ammonia (NH3) Antidiuretic Hormone (ADH) increases the water
combines with secreted H+ ions to form a permeability of the distal tubule and collecting
non-diffusible ammonium ion (NH4-) which duct, thus increasing the concentration of urine. In
is excreted in the urine. Ammonia production contrast, when secretion of ADH is inhibited, it
is increased by a severe metabolic acidosis to allows dilute urine to be formed. This occurs mainly
as much as 700 mmol.day-1. when plasma sodium concentration falls such as
following drinking large quantities of water. This
Excretion of waste products fall is detected by the osmoreceptors (above). The
Filtration occurs as blood flows through the hormones interact when blood loss or dehydration
glomerulus. Some substances not required by the occurs to maintain intravascular volume. The flow
body, and some foreign materials (e.g. drugs) may diagram in Table 2 illustrates this.
not be cleared by filtration through the glomerulus. Other Substances Produced by the kidney
Such substances are cleared by secretion into the 1,25 dihydroxy vitamin D (the most active form
tubule and excreted from the body in the urine. vitamin D) which promotes calcium absorption
Hormones and the Kidney from the gut.
Renin (see above) increases the production of
angiotensin II which is released when there is a fall Erythropoietin which stimulates red cell production
in intravascular volume e.g. haemorrhage and
dehydration. This leads to: Both of these decrease in renal failure.
l Constriction of the efferent arteriole to
maintain GFR, by increasing the
filtration pressure in the Table 2.
glomerulus.
l Release of aldosterone from the
adrenal cortex
l Increased release of ADH from
the posterior pituitary
l Thirst
l Inotropic myocardial stimulation
and systemic arterial constriction
The opposite occurs when fluid
overload occurs.