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Anesthetic Management of Patient With Chronic Renal Failure

Anesthetic Management of Patient With Chronic Renal Failure. Dr Sanjeev Aneja MD. DNB, FFARCS Sr Consultant in Anesthesia & Intensive Care. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Important Terms & Definitions. Renal Failure Chronic Renal Failure GFR

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Anesthetic Management of Patient With Chronic Renal Failure

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  1. Anesthetic Management of Patient With Chronic Renal Failure Dr Sanjeev Aneja MD. DNB, FFARCS Sr Consultant in Anesthesia & Intensive Care www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  2. Important Terms & Definitions • Renal Failure Chronic Renal Failure • GFR • Creatinine Clearance • Azotemia & Uremia • BUN/ Creatinine • Auto regulation of Renal blood Flow

  3. 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)

  4. Stages of Chronic Kidney Disease (NKF,2003)

  5. 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

  6. GFR contd. • Estimation of GFR using exogenous filtration marker • Estimation of GFR using endogenous filtration markers urea creatinine Cystatin C

  7. GFR contd • Estimating equations for GFR using serum creatinine • Cockcroft-Gault Equation Ccr= (140-Age) x weight( 0.85 if female)/(72xPcr) MDRD study equation

  8. 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

  9. Discussion • History Duration of disease Cause of disease Manifestation of systemic disease Complications of CRF

  10. History • Type of dialysis • Frequency of dialysis • Tolerance of dialysis • Dry weight of the patient

  11. Physical Examination Mark & Record the site of venous access for Dialysis

  12. 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

  13. CVD in CKD • Hypertension • Uremia • Anemia • Coronary & valvular calcification • Dyslipidemia • Increased markers of inflammation

  14. 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

  15. Assessment of Other Systems • Respiratory • Hematology • Fluid & Electrolyte • Gastro intestinal

  16. Pre Operative Preparation • Treat anemia • Dialysis When to Dialyse How much fluid to be removed Effects of Dialysis

  17. Anesthesia planning • GA Vs Regional • Premedications • Intraoperative Management • Post operative pain & fluid management

  18. Anesthesia for Renal Transplantation 1936 (VORONOY) 1st Cadaver Human Renal Allograft 1954 (MERRILL) 1st Living related donor graft between twins. 5 Years Survival After Transplants: 70% After Dialysis: 30% (8 out of 23,546 Pts.) (Anaestesiology clinics of North America, 22, 2004)

  19. 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)

  20. Pre-operative Preparation Pre-Op visit Reassurance ICU 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

  21. 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)

  22. Conduct of Anaesthesia Induction: Rapid Sequence induction Propfol / Thiopentone / Ketamin Fentanyl (5mcg/kg) / Esmolol Atracurium / O2 + N2O + isoflurane ? Sevoflurane (Compound A controversy)

  23. 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

  24. 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.

  25. Immunosuppression Methyl Prednisolon – (500 mg. Solumedrol) IV Slowly (30-60 mins) before transplant. Cardiac Arrest Arrhythmias Circulatory Collapse Azathioprim Cyclosporin

  26. Post operative period Recovery ICU Stay – Protocols – Fluid / Urine output. Pain Relief – PCA / Epidural Haemodialysis CXR

  27. Dual Kidney Transplant Two kidneys from aged donor are placed in to one recipient. Long duration of surgery / Otherwise no difference in management.

  28. Thank you www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  29. 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

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