Management Of Anesthesia In

Chronic Renal Failure Patients

(brief practical review)

Reza Aminnejad; M.D.

Anesthesiologist.
In The Name of God
Chronic Renal Failure
CRF
 CRF is the progressive, irreversible
deterioration of renal function that
results from a wide variety of diseases.
 Diabetes mellitus is the leading cause
of end-stage renal disease (ESRD)
followed closely by systemic
hypertension.
 TABLE 14-5   -- Causes of Chronic Renal Failure

Glomerulopathies   
Primary glomerular disease  
Focal glomerulosclerosis  
Membranous nephropathy  
Ig A nephropathy   
MPGN (Mmmbranoproliferative Glomerulonephritis)  
Glomerulopathies associated with systemic disease  (DM, Amyloidosis, Postinfectious
glomerulonephritis, SLE, Wegener's granulomatosis 
Tubulointerstitial disease
Analgesic nephropathy
Reflux nephropathy with pyelonephritis
Myeloma kidney
Sarcoidosis  
Heredity disease   
Polycystic kidney disease  
Alport syndrome  
Medullary cystic disease  
Systemic hypertension  
Renal vascular disease  
Obstructive uropathy  
Human immunodeficiency virus
In renal failure
 Only 10% of nephrons are functioning.
 GFR is less than 12 ml/min
 Uremia is present.
 Increased BUN & Cr, anemia, hyperkalemia &
increased BT can be seen.
 Other symptoms associated with CRF include
cognitive impairment, peripheral neuropathy,
infertility, and increased susceptibility to
infection
Comorbidities
 CRF and cardiac disease are intimately
linked, and as CRF progresses,
coronary artery disease and congestive
heart failure contribute to
symptomatology.
Classification of Chronic Renal Disease

 Stage 1: Kidney damage with normal or

↑ GFR (≥90 ml/min)
 Stage 2: Kidney damage with mild ↓
GFR (60–89 ml/min)
 Stage 3; Moderate ↓ GFR (30–59
ml/min)
 Stage 4: Severe ↓ GFR (15–29 ml/min)
 Stage 5: Kidney failure with GFR<15 or
need to dialysis
Definition of Chronic Kidney Disease

 CKD is defined as either kidney

damage or a GFR less than 60
mL/min/1.73 m2 for 3 months or
more. Kidney damage is defined as a
pathologic abnormality or markers of
damage including abnormalities of the
blood or on urine or imaging studies.
Manifestations of CRF
Electrolyte imbalance
   Hyperkalemia
   Hypermagnesemia  
Hypocalcemia
Metabolic acidosis  
Unpredictable intravascular fluid volume status  
Anemia   
Increased cardiac output  
Oxyhemoglobin dissociation curve shifted to the right  
Uremic coagulopathies   
Platelet dysfunction  
Neurologic changes   
Encephalopathy  
Cardiovascular changes   
Systemic hypertension  
Congestive heart failure 
Attenuated sympathetic nervous system activity due to treatment with
antihypertensive drugs  
Renal osteodystrophy  
Pruritus
Diagnosis of Chronic Renal Insufficiency
 Oliguria does not set in until late in the
disease and is an unreliable marker of
disease progression.
 diagnosis is made from signs and
symptoms of fluid overload and
concomitant cardiac disease and
confirmed by laboratory testing .
 Proteinuria & urinary sediment are also
helpful in diagnosis.
Anesthetic Management
 An important assessment is whether the renal
disease is stable, progressing, or diminishing.
 Drugs that their action is terminated by renal
excretion are: Gallamine, Metocurine,
Digoxin, Inotropes, Aminoglycosides,
vancomycin, Cephalosporin & penicillin.
 Drugs that their action is partially terminated
by renal excretion are: Barbiturates,
Pancuronium, Vecuronium, Neostigmine,
Edrophonium, Atropine, Glycopyrrolate,
Milrione, Hydralazine, Sulfonamides.
Preoperative Evaluation
 Means of blood volume status assesment:
Comparing body weight before and after
hemodialysis, Monitoring vital signs & Measuring
atrial filling pressures.
 Glucose management in diabetic patients is of
concern.
 Preoperative medication must be individualized.
 Patients on hemodialysis should undergo dialysis
during the 24 hours preceding elective surgery
(serum potassium concentration should not exceed
5.5 mEq/L on the day of surgery)
 Anemia is evaluated preoperatively.
 The preoperative presence of a coagulopathy may be
treated with DDAVP.
 Induction of Anesthesia
 Intravenous anesthetic drugs (propofol, etomidate, thiopental)
are safe.
 These patients may exhibit uremia-induced slowing of gastric
emptying.
 Slow injection of induction drugs is preferred to minimize the
likelihood of drug-induced decreases in systemic blood
pressure (regardless of blood volume status, these patients
often respond to induction of anesthesia as if they were
hypovolemic)
 Small decreases in blood volume, institution of PPV of the
patient's lungs, abrupt changes in body position, or drug-
induced myocardial depression can result in an exaggerated
decrease in systemic blood pressure.
 Maximum drug-induced potassium release is 0.5–1.0 mEq/L
 Small doses of nondepolarizing muscle relaxants
administered before the injection of succinylcholine do not
reliably attenuate the succinylcholine-induced release of
Maintenance of Anesthesia
 Nitrous oxide combined with isoflurane, desflurane, or short-
acting opioids is a preferred combination for dialysis dependent
patients.
 Sevoflurane may be avoided because of concerns related to
fluoride nephrotoxicity or production of compound A.
 TIVA with remifentanil, propofol, and cisatracurium has been
recommended for patients with end-stage renal failure.
 Opioids decrease the likelihood of cardiovascular depression
and avoid the concern of hepatotoxicity or nephrotoxicity.
opioids do not reliably control intraoperative SBP elevations.
Furthermore, prolonged sedation and depression of ventilation
from small doses of opioids have been described in anephric
patients. Conceivably, pharmacologically active metabolites of
opioids accumulate in the circulation and cerebrospinal fluid
when renal function is absent.
Muscle Relaxants
 Clearance of mivacurium, atracurium, and
cisatracurium from plasma is independent of renal
function.
 It seems prudent to decrease the initial dose of the
drug and administer subsequent doses based on the
responses observed using a peripheral nerve
stimulator.
 Other explanations except residual neuromuscular
blockade (antibiotics, acidosis, electrolyte
imbalance, diuretics) should be considered when
neuromuscular blockade persists or reappears in
patients with renal dysfunction because renal
excretion accounts for approximately 50% of the
clearance of neostigmine and approximately 75% of
the elimination of edrophonium and pyridostigmine.
Fluid Management and Urine Output
in Hemodialysis Dependent Patients
 Noninvasive operations require replacement of
only insensible water losses with 5% glucose in
water (5–10 mL/kg IV).
 The small amount of urine output can be
replaced with 0.45% sodium chloride.
 Third space loss is often replaced with balanced
salt solutions or 5% albumin solutions.
 Measuring the central venous pressure may be
useful for guiding fluid replacement.
Monitoring
 For invasive monitoring radial, ulnar, brachial &
axillary arteries should be avoided (they are
needed for AVF in the future).
 Catheterization of femoral artery carries the risk
of line infection.
 ( 1 ) the catheter must be accessed aseptically,
just as it is at the time of dialysis, ( 2 ) the
catheter is left heparinized and must be aspirated
before connecting to an intravenous line or
pressure transducer, ( 3 ) if it is to be
disconnected at the end of the procedure, it must
be reheparinized and sealed aseptically again.
Associated Concerns
 premedication may or may not be necessary.
 Intramuscular injection of any premedication
should be avoided in consideration of low
muscle mass and uremic platelet dysfunction.
 Attention to patient positioning on the
operating room table is important.
 Guidelines recommend that arm veins of the
nondominant hand not be used for
intravenous cannulas and to even advise
patients to wear Medic Alert bracelets to this
effect
Regional Anesthesia
 Adequacy of coagulation should be
considered and the presence of
uremic neuropathies excluded
before regional anesthesia is performed
in these patients.
 Co-existing metabolic acidosis may
decrease the seizure threshold for
local anesthetics.
Postoperative Management
 Consideration of inadequate reversal of
muscle relaxant in anephric patients who
show signs of skeletal muscle weakness
 Caution in the use of parenteral opioids
 Continuous monitoring of the ECG is helpful
for detecting cardiac dysrhythmias
(Hyperkalemia)
 Continuation of supplemental O2 into the
postoperative period (anemia)