anesthetic management of patient with chronic renal failure dr sanjeev aneja md. dnb, ffarcs sr...
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Anesthetic Management of Patient With Chronic Renal Failure
Dr Sanjeev Aneja MD. DNB, FFARCS
Sr Consultant in Anesthesia & Intensive Care
www.anaesthesia.co.in [email protected]
Important Terms & Definitions
Renal Failure Chronic Renal Failure GFR Creatinine Clearance Azotemia & Uremia BUN/ Creatinine Auto regulation of Renal blood Flow
Chronic Kidney Disease
Presence for at least three months of either of the following
Structural or functional abnormality of kidney with or without fall in GFR
GFR <60ml/ml/1.73sq mt (NKF 2003)
Stages of Chronic Kidney Disease (NKF,2003)
Stage Description GFR
1 Kidney Damage with normal GFR
>/=90
2 Kidney Damage with mild fall in GFR
60-89
3 Moderate fall in GFR 30-59
4 Severe fall in GFR 15-29
5 Kidney Failure <15
GFR
Best overall measure of function Normal level of GFR varies with age, sex &
physiological state 25% of individuals above 70 yr of age have
GFR <60 ml GFR is estimated from urinary clearance of a
filtration marker
GFR contd.
Estimation of GFR using exogenous filtration marker
Estimation of GFR using endogenous filtration markers
urea creatinine Cystatin C
GFR contd
Estimating equations for GFR using serum Estimating equations for GFR using serum creatininecreatinine
Cockcroft-Gault Equation
Ccr= (140-Age) x weight( 0.85 if female)/(72xPcr)
MDRD study equationMDRD study equation
Chronic Kidney disease & Anesthetist
Patients on replacement support
pts. With GFR<15 ml
pts. With GFR 15-29 ml
Patents with GFR 30-59 ml
Mr. Sharma’s story
48 year old man with diabetes, hypertension and chronic renal insufficiency on biweekly dialysi sadmitted for electivelaproscopic cholecystectomy. He also suffers from hiatus hernia
His medications are captopril, and insulin.
HR: 72, BP: 180/106, pedal edema ++, Pallor ++, facial puffiness +,
Chest: Crepts+ B/L
Hb= 6, Plt.= 1.03, Na= 138, K=5.8, Cl=110, HCO3=16, BUN80, Cr=7.04,Glu=129
ECHO: mod. Conc. LVH, Gen. Hypokinesis, EF= 35%
Mr. Sharma’s story
Discussion
HistoryHistory Duration of disease
Cause of disease
Manifestation of systemic disease
Complications of CRF
History
Type of dialysis Frequency of dialysis Tolerance of dialysis Dry weight of the patient
Physical Examination
Mark & Record the site of Mark & Record the site of venous access for Dialysisvenous access for Dialysis
Cardiovascular Disease in CKD
CVD is the main cause of death in patients with CKD
Persons with CKD are predisposed to three types of CVD—atherosclerosis, arteriosclerosis, and cardiomyopathy
CVD in CKD
Hypertension Uremia Anemia Coronary & valvular calcification Dyslipidemia Increased markers of inflammation
CVD in CKD
No guidelines for cardiovascular evaluation in ESRD patients
Pt. <50yr no diabetes & symptom of CAD
Pt..50yr with diabetes without symptom of CAD
Pt. With symptom of CAD or CHF
Assessment of Other Systems
Respiratory
Hematology Fluid & Electrolyte
Gastro intestinal
Pre Operative Preparation
Treat anemia
Dialysis When to Dialyse How much fluid to be removed Effects of Dialysis
Anesthesia planning
GA Vs Regional
Premedications
Intraoperative Management
Post operative pain & fluid management
Lata’s story
30 year old woman with diabetes, hypertension and chronic renal insufficiency (baselinecreatinine of 4.5) presents to . Her medications are captopril, HCTZ and insulin. Physical exam is unremarkable. She is for live relted kidney transplantation
Na= 138, K=5.8, Cl=110, HCO3=16, BUN=70, Cr=4.5,Glu=129 Hb 8.0gm
EF 35%, PT/PTT Normal
Lata’s story
Lata’s story
Anesthesia for Renal Transplantation
1936 (VORONOY) 1st Cadaver Human Renal Allograft
1954 (MERRILL) 1st Living related donor graft between twins.
5 Years SurvivalAfter Transplants: 70%After Dialysis: 30%
(8 out of 23,546 Pts.)(Anaestesiology clinics of North America, 22, 2004)
Surgical Field: Renal Transplant
Extra Peritoneal
Donor Renal Artery
To external / common iliac Artery
Donor Renal Vein
To external / common iliac vein
Donor Ureter
To Bladder (Ureterocystostomy)
Pre-operative Preparation
Pre-Op visit ReassuranceICU Stay/Central Line/Pain Relief/PCA-Epidural.Hep. B,C/ HIV Status.A-V Fistula
Fluid/Electrolyte Status
Plan of Immunosuppression Therapy – Cotisone / Cychosparin / Azathioprine
Choice of Anaesthetic Technique
General Anaesthesia (GA)
Regional Anaestehsia (RA) – Spinal/Epidural/CSE
Combination of GA + RA
? Epidural haematoma
? Use of RA in Autonomic neuropathy
?Use of Vasopressors (avoided)
Conduct of Anaesthesia
Induction:Rapid Sequence inductionPropfol / Thiopentone / KetaminFentanyl (5mcg/kg) / EsmololAtracurium /O2 + N2O + isoflurane
? Sevoflurane (Compound A controversy)
Equipment / Monitoring
Sterile disposable anaesth. circuits / ETT / Laryngoscope
Use of gloves / Gowns / IV Lines (avoid forearm)
NIBP / ECG / SPO2 / ETCO2 / PN Stimulator / agent / Temperature / CVP (IJV) / Urine Output
Electrolytes / ABG / haemotocrit? IBP / ?PAWP
Fluid & Diuretic Therapy (Intra – op.)
Adequacy of Perfusion at vascular clamp release.
Intra-op volume expansion - ↑ RBF & improved immediate graft function / graft survival / lower pts mortality.
Guided by CVP (10-15cm H2O)Small vol. colloid / N-saline (Avoid RL)
Cadaver Kidney – needs ↑ BP & ↑ plasma vol. to initiate diuresis than normal kidney.
Frusemide / Mannitol / Dopamine infusion.
Immunosuppression
Methyl Prednisolon – (500 mg. Solumedrol)IV Slowly (30-60 mins) before transplant.Cardiac ArrestArrhythmiasCirculatory Collapse
AzathioprimCyclosporin
Post operative period
Recovery
ICU Stay – Protocols – Fluid / Urine output.
Pain Relief – PCA / Epidural
Haemodialysis
CXR
Dual Kidney Transplant
Two kidneys from aged donor are placed in to one recipient.
Long duration of surgery / Otherwise no difference in management.
Clinical settings when BUN and creatinine levels may not reflect alteration in renal function
High urea with normal renal function: Hypercatabolism, high protein load, GI bleed, hematoma breakdown
Normal urea with decreased renal function: Decreased urea synthesis in hepatic failure or malnutrition
High creatinine with normal renal function: Excess creatinine release due to seizures, muscle injury, inflammation, or ischemia
Normal creatinine with decreased renal function: Decreased creatinine synthesis from muscle due to malnutrition or atrophic muscular disorders