Anesthetic Management of Patient With Chronic Renal Failure

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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 anaesthesia.co.in_at_gmail.c
om
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Important Terms Definitions

• Renal Failure
• Chronic Renal Failure
• GFR
• Creatinine Clearance
• Azotemia Uremia
• BUN/ Creatinine
• Auto regulation of Renal blood Flow

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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 lt60ml/ml/1.73sq mt
• 
  (NKF 2003)

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Stages of Chronic Kidney Disease (NKF,2003)
Stage Description GFR
1 Kidney Damage with normal GFR gt/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 lt15

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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
  lt60 ml
• GFR is estimated from urinary clearance of a
  filtration marker

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GFR contd.

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

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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

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Chronic Kidney disease Anesthetist

• Patients on replacement support
• pts. With GFRlt15 ml
• pts. With GFR 15-29 ml
• Patents with GFR 30-59 ml

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Discussion

• History
• Duration of disease
• Cause of disease
• Manifestation of systemic disease
• Complications of CRF

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History

• Type of dialysis
• Frequency of dialysis
• Tolerance of dialysis
• Dry weight of the patient

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Physical Examination

• Mark Record the site of venous access for
  Dialysis

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Cardiovascular Disease in CKD

• CVD is the main cause of death in patients with
  CKD
• Persons with CKD are predisposed to three types
  of CVDatherosclerosis, arteriosclerosis, and
  cardiomyopathy

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CVD in CKD

• Hypertension
• Uremia
• Anemia
• Coronary valvular calcification
• Dyslipidemia
• Increased markers of inflammation

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CVD in CKD

• No guidelines for cardiovascular evaluation in
  ESRD patients
• Pt. lt50yr no diabetes symptom of CAD
• Pt..50yr with diabetes without symptom of CAD
• Pt. With symptom of CAD or CHF

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Assessment of Other Systems

• Respiratory
• Hematology
• Fluid Electrolyte
• Gastro intestinal

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Pre Operative Preparation

• Treat anemia
• Dialysis
• When to Dialyse
• How much fluid to be removed
• Effects of Dialysis

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Anesthesia planning

• GA Vs Regional
• Premedications
• Intraoperative Management
• Post operative pain fluid management

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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)

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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)

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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

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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)

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Conduct of Anaesthesia

• Induction
• Rapid Sequence induction
• Propfol / Thiopentone / Ketamin
• Fentanyl (5mcg/kg) / Esmolol
• Atracurium /
• O2 N2O isoflurane
• ? Sevoflurane (Compound A controversy)

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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

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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.

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Immunosuppression

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

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Post operative period

• Recovery
• ICU Stay Protocols Fluid / Urine output.
• Pain Relief PCA / Epidural
• Haemodialysis
• CXR

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Dual Kidney Transplant

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

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Thank you
www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
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