Textbook Reading

Surgery in ESRD
Patients
Michael J. Moritz, MD, and Vincent T. Armenti,
MD, PhD

Introduction
ESRD patients are at increased risk for some perioperative
complications.
Increasing morbidity & mortality.
General surgery
the combined mortality was approximately 4 percent, ranging between
a low of 0 percent to a high of 47 percent in emergency cases.
The morbidity rate was 54 percent (range 12 to 64 percent).

Cardiac surgery mortality and morbidity rates of 10 and 46

percent.

 The cause of the increased morbidity and mortality with dialysis

may be attributed to a number of factors:
1. A high incidence of coronary artery disease and myocardial
dysfunction.

2. Difficulty adjusting fluid and electrolytes in the perioperative period in

patients who are anephric. Hyperkalemia is the most common
complication, possibly requiring immediate postoperative dialysis.

3. Failure to normally excrete and/or metabolize anesthetics and analgesics,

leading to toxic levels of these agents.

4. Increased bleeding complications.

5. Poor blood pressure control, including hypertension and hypotension.

MEDICAL MANAGEMENT OF
THE DIALYSIS PATIENT
UNDERGOING SURGERY

The principal pre-, intra-, and/or postoperative issues of concern relating

to the medical management of the dialysis patients include the following:

1. General laboratory
evaluation
2. Anemia status
3. Nutritional status
4. Dialysis dose
5. Fluid and electrolyte
management
6. Blood pressure control

7.

Evaluation for cardiovascular disease and

the use of beta blocker medication
8.
Correction of a bleeding diathesis
9.
Antibiotic administration
10. Glucose metabolism
11. Intravenous access
12.

Anesthetic considerations

Preoperat
ive
Assessme
nt

Indications for Elective Surgery

in ESRD

Normal Electrolytes
SC 7 mg/dl
BUN 100 mg/dl
Hb 8 mg/dl

Anemia status
Elective surgery it is possible to boost the
hemoglobin concentration to optimum levels by the
judicious use of additional erythropoiesis-stimulating
agents (ESAs).
This is important because transfusions are frequently
necessary postoperatively due to substantial intra- or
postoperative blood loss and the postoperative state is
characterized by ESA resistance.

Nutrition
The ability to heal after surgery may be
maximized by ensuring that the dialysis patient
is well-nourished.
Parameters utilized to assess nutritional status
such as the protein catabolic rate and serum
concentration of albumin should be
optimized prior to the operation, if possible.

Intensive dialysis
Whether the delivery of intensive doses of dialysis prior to
or during surgery improves outcomes is unknown.
With peritoneal dialysis, about a week before surgery:
An additional exchange each day for continuous ambulatory
peritoneal dialysis patients seems a reasonable approach

An extra hour or two on the cycler each day for automated

peritoneal dialysis patients may also be helpful

Another goal of additional dialysis preoperatively is to

reassess and achieve the dry weight, which is often
changing.

Fluid
Achieving optimal volume status prior to surgery
correctly estimating the amount of fluid to be
administered and/or lost during surgery:
If euvolemia or "dry weight" (which is an estimated guess) is
achieved the patient receives a large volume of fluid during
surgeryhypervolemia and possibly pulmonary edema can
occur in the immediate postoperative perioddialysis.
If too much fluid is removed risk of hypotension during
anesthesia-induced systemic vasodilatation thrombosis of the
arteriovenous access.

 The type of intraoperative fluid administered should

also be reviewed.
In patients without renal failure, the most common
intraoperative fluid given is "lactated Ringers," a
solution that contains potassium.
Thus, the preferred solution in dialysis patients is
isotonic saline.
However, based upon the specific acid-base and
electrolyte abnormalities, different fluids may be
required, including specially tailored solutions.

Hyperkalemia
Intraoperatively and postoperatively, potassium can rise
abruptly for several reasons.
1. Potassium will redistribute from the intracellular to the
extracellular space from metabolic acidosis, tissue
trauma, hemolysis, and resorbing hematoma.
2. Neuromuscular blocking agents (one component of
general anesthesia) generally cause a small rise in
serum potassium.
3. Stored red blood cells

Hypertension
Preoperative and intraoperative hypertension is
common in patients with chronic kidney
disease.
Contributing factors include anxiety, a
catecholamine response related to the stress
of surgery, and baseline hypertension caused
by kidney failure.

 With few exceptions, patients who have kidney

disease and hypertension should continue
antihypertensive drug therapy throughout the
surgical period.
Oral agents that cannot be given intravenously may
be replaced with transdermally administered
clonidine two to three days before surgery or with an
intravenously administered agent.

 Diuretics discontinued two to three days before surgery.

Discontinuationis necessary to avoid possible volume depletion and
intraoperative hypotension, which may worsen renal function.

Hypoglycemia may also cause hypertension as a result of

catecholamine release for mobilization of glycogen stores.
This most commonly occurs in patients with diabetes mellitus who
are kept on NPO status for a prolonged period before surgery.

Hypotension
Hypotension in dialysis patients may result from a number
of factors.
1. Excessive fluid removal in dialysis, which is most common
2. Left ventricular dysfunction
3. Interference with sympathetic function due to diabetic
autonomic neuropathy, acquired dysautonomia of recumbency,
or the administration of sympatholytic medications
4. Pericardial tamponade
5. Vasodilation from opioid analgesics or other medications
administered to alleviate pain or anxiety

Cardiovascular evaluation
Coronary artery disease and myocardial
dysfunction are the most common comorbidities in
patients with renal failure.
Heart disease results in significant morbidity and
mortality in patients with end-stage renal disease,
even among those not undergoing surgery.
The evaluation of patients with known or suspected
cardiac disease prior to noncardiac surgery
requires an appraisal of the patient's clinical risk
profile in the context of the surgery to be

Coagulopathy
Uremic coagulopathy is complex and multifactorial.
Most components of the coagulation system as measured
are normal in ESRD patients, including the plasma levels
of clotting factors, the number of platelets, the
coagulation tests (prothrombin time and PTT), and the
function of the fi brinolytic system.
On the other hand, the bleeding time is often abnormally
prolonged in dialysis patients, reflecting coagulopathy.

Heparin
It is preferable not to use heparin during dialysis
on the day of surgery.
If more emergent surgery is required, the effect
of heparin can be reversed by administering
protamine.
After major surgery, heparin with dialysis should
be avoided for 24 to 48 hours.

Perioperative antibiotics
In general, perioperative antibiotics should be
administered in accordance with general
surgical principles, including appropriate dosing
adjustments for patients with renal function.
The loading dose of antibiotics is usually
the same in dialysis patients as in normal
individuals.

Glucose metabolism
Glucose intolerance is also a feature of uremia.
The art of managing diabetic patients with end-stage renal disease
relies upon close monitoring of blood glucose levels and a close
familiarity with the behavior and insulin requirements of each
patient.
Some additional recommendations include the following:
1. Intravenous fluids should contain dextrose if the patient is fasting; insulin coverage is
adjusted accordingly.
2. Unless contraindicated, peritoneal dialysis patients should continue exchanges while
waiting for surgery; however, their peritoneum should be drained prior to surgery.

Intravenous access
Since frequent IVs may destroy future access sites, IVs should not
be routinely placed unless necessary.
Central lines should also not be placed on the same side as the
arteriovenous access.
Patients need to be taught to remind health care professionals not
to use the designated arm needle sticks or blood pressure
measurements in the arm

Intraoperative Considerations
Safe intraoperative care: protection of the
patients current hemodialysis access, and
protection of veins that may be used in the future
for creation of arteriovenous fistulae for
hemoaccess.
anesthetic drugs
neuromuscular blocking agents that are not
dependent on renal excretion.
narcotics dose used should be lowered both
intraoperatively and postoperatively.

 Management of the peritoneal dialysis catheter

during abdominal surgery

clean abdominal procedures the catheter
can be left in place & a temporary venous
catheter placed for hemodialysis access until
the wound is sufficiently healed to resume
peritoneal dialysis.
dirty cases (the catheter is likely to become
contaminated) remove the catheter and start
anew after recovery.

Postoperative Considerations
Especially for abdominal surgeries lees used
nasogastric tube because of the increased
incidence of gastroparesis in ESRD patients.
The serum sodium should be followed to watch for
hyponatremia.
Potassium-containing solutions such as lactated
Ringers should be avoided.

 Postoperative hyperkalemia can result from all of the

causes previously noted.
For most postoperative patients, urinary output is used as a
measure of adequate circulating volume.
The most common causes of postoperative fever are
atelectasis, wound or urinary tract infection, and
thrombophlebitis.
In dialysis patients, urinary infections can still occureven in the
anuric patient, who may develop pyocystis

 Postoperative management of hypertension in

patients who are NPO requires careful attention.
Intravenous antihypertensives given by
continuous infusion (such as nicardipine) are very
effective.
Most medications can be continued orally with a
sip of water or via nasogastric tube.

Summary
Dialysis patients are at increased cardiovascular risk for
surgery.
The other risks of surgery are generally controllable with
careful attention to the patients history, ongoing physical
examination, medications, operative technique, and
laboratory studies.

MATUR SUKSMA

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