Anaesthetic drugs in CKD 197

• Anaesthesia for A–​V fistula formation: ask the surgeon where the fistula
is to be formed. Local infiltration works well for brachiobasilic fistulae.
An axillary/​supraclavicular brachial plexus block is recommended for
a brachiocephalic fistula, and evidence shows a better fistula outcome.
Patients may need extra LA in the axilla and mild sedation. Avoid
hypotension to prevent fistula thrombosis. The fistula may be used for
dialysis after 3–​4w. Synthetic grafts can be used immediately but do not
last as long.
• Peritoneal dialysis uses the large surface area of the peritoneum to
exchange fluid and metabolites via temporary (hard) or permanent
Tenckhoff (soft) catheters in the lower abdomen. It is inefficient
but can run continuously. Catheter placement or removal usually
requires a mini-​laparotomy but can be done under LA ± sedation if
necessary. Dialysis fluid should be drained before anaesthesia to prevent
respiratory function compromise. Patients can usually omit 24–​48h of
postoperative dialysis, but a period of haemodialysis may be needed if
undergoing bowel surgery.
• Most antibiotics are excreted by the kidney. It is common to use a
normal loading dose, with reduced and/​or delayed maintenance doses.
If in doubt, check in the British National Formulary (BNF) or with a
microbiologist.

Table 7.2  Anaesthetic drugs and CKD

Safe drugs Drugs safe in limited Contraindicated
or reduced doses drugs
Premedication Lormetazepam,
midazolam, temazepam
Induction Propofol Ketamine, etomidate,
thiopental
Maintenance Isoflurane, desflurane, Sevoflurane Enflurane
halothane, propofol
Muscle Suxamethonium, Vecuronium, Pancuronium
relaxants atracurium, rocuronium
cisatracurium
Opioids Alfentanil, remifentanil Fentanyl, morphine, Pethidine,
oxycodone codeine,
tramadol
Local Bupivacaine, lidocaine
anaesthetics (reduce dose by 25%)
Analgesics Paracetamol NSAIDs
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198 Chapter 7 Renal disease

Acute kidney injury

AKI is defined as any of the following:
• Increase in serum creatinine by ≥0.3mg/​dL within 48h; or
• Increase in serum creatinine by ≥1.5 times the baseline, which is known
or presumed to have occurred within the prior 7d; or
• Urine volume <0.5mL/​kg/​h for 6h.
AKI is categorized into three stages:
Stage 1 is defined as any one of the following:
• An increase in serum creatinine by ≥26micromol/​L within 48h
• A ≥50% rise in serum creatinine within 7d (25% in children)
• Urine volume <0.5mL/​kg/​h for 6h (>8h in children)
Stage 2: serum creatinine doubles and/​or urine <0.5mL/​kg/​h ≥12h
Stage 3 is defined as any one of the following:
• Serum creatinine triples or >354 micromoles/​L
• Anuria ≥12h or <0.3mL/​kg/​h urine for ≥24h
• Renal replacement therapy required
• eGFR <35mL/​min in patients <18y.
Perioperative management of AKI
AKI developing in the perioperative period has a high mortality. Table 7.3
highlights the risk factors for developing AKI.

Table 7.3  Risk factors for perioperative AKI

Pre-​existing CKD, DM, liver disease, cardiovascular disease, previous

AKI, neurological or cognitive impairment affecting diet,
over 65y
Perioperative Sepsis, hypotension, hypovolaemia, dehydration
Drugs Nephrotoxins: antibiotics, NSAIDs, ACE inhibitors,
lithium, chemotherapy agents, radiological contrast media
Trauma Rhabdomyolysis (myoglobinaemia from crush injuries)
Surgery Emergency, intraperitoneal, biliary surgery in the
presence of obstructive jaundice (hepatorenal syndrome)
Renal and abdominal vascular surgery
Intra-​abdominal Any cause of abdominal distension
hypertension
Urinary obstruction

Considerations
• Preoperative rehydration is essential, and any fluid deficit should be
corrected before surgery. Invasive monitoring may be needed.
• Remember that an adequate BP is needed for renal perfusion and
this is relative to the patient’s baseline. A MAP under 80mmHg for
≥10min has been linked to i risk of AKI,4 but this may be inadequate in
hypertensives. Inotropes may be required.
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200 Chapter 7 Renal disease

Further reading
National Institute for Health and Care Excellence (2013). Acute kidney injury: prevention, detection and
management. NICE guideline [NG148]. M https://​www.nice.org.uk/​guidance/​ng148

References
1 Kidney Disease Improving Global Outcomes (2012). KDIGO 2012 clinical practice guideline for
evaluation and management of chronic kidney disease, Kidney Int, 3, 1–​150. M https://​kdigo.org/​
wp-​content/​uploads/​2017/​02/​KDIGO_​2012_​CKD_​GL.pdf
2 McLean DJ, Shaw AD (2018). Intravenous fluids: effects on renal outcomes. Br J Anaesth, 120,
397–​402.
3 de Souza CM, Tardelli MA, Tedesco H, et al. (2015). Efficacy and safety of sugammadex in the
reversal of deep neuromuscular blockade induced by rocuronium in patients with end stage renal
disease. Eur J Anaesthesiol, 32, 681–​6.
4 Wesselink EM, Kappen TH, Torn HM, et al. (2018). Intraoperative hypotension and the risk of
postoperative adverse outcomes: a systematic review. Br J Anaesth, 121, 706–​21.
 

Chapter 8 201

Hepatic disease
Ashleigh Williams and John Christie
Liver disease 202
Anaesthetic management of patients with liver disease 205
Drug metabolism and liver disease 211
Postoperative liver dysfunction or jaundice 212