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Anesthetic Management of Patient With Chronic Renal Failure

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Title: Anesthetic Management of Patient With Chronic Renal Failure


1
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
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 lt60ml/ml/1.73sq mt

  • (NKF 2003)

4
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

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
    lt60 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 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

13
History
  • Type of dialysis
  • Frequency of dialysis
  • Tolerance of dialysis
  • Dry weight of the patient

14
Physical Examination
  • Mark Record the site of venous access for
    Dialysis

15
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

16
CVD in CKD
  • Hypertension
  • Uremia
  • Anemia
  • Coronary valvular calcification
  • Dyslipidemia
  • Increased markers of inflammation

17
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

18
Assessment of Other Systems
  • Respiratory
  • Hematology
  • Fluid Electrolyte
  • Gastro intestinal

19
Pre Operative Preparation
  • Treat anemia
  • Dialysis
  • When to Dialyse
  • How much fluid to be removed
  • Effects of Dialysis

20
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)

25
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)

26
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

27
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)

28
Conduct of Anaesthesia
  • Induction
  • Rapid Sequence induction
  • Propfol / Thiopentone / Ketamin
  • Fentanyl (5mcg/kg) / Esmolol
  • Atracurium /
  • O2 N2O isoflurane
  • ? Sevoflurane (Compound A controversy)

29
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

30
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.

31
Immunosuppression
  • Methyl Prednisolon (500 mg. Solumedrol)
  • IV Slowly (30-60 mins) before transplant.
  • Cardiac Arrest
  • Arrhythmias
  • Circulatory Collapse
  • Azathioprim
  • Cyclosporin

32
Post operative period
  • Recovery
  • ICU Stay Protocols Fluid / Urine output.
  • Pain Relief PCA / Epidural
  • Haemodialysis
  • CXR

33
Dual Kidney Transplant
  • Two kidneys from aged donor are placed in to one
    recipient.
  • Long duration of surgery / Otherwise no
    difference in management.

34
Thank you
www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
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