Title: Anesthetic Management of Patient With Chronic Renal Failure
1Anesthetic 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
2Important Terms Definitions
- Renal Failure
- Chronic Renal Failure
- GFR
- Creatinine Clearance
- Azotemia Uremia
- BUN/ Creatinine
- Auto regulation of Renal blood Flow
3Chronic 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)
4Stages 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
5GFR
- 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
6GFR contd.
- Estimation of GFR using exogenous filtration
marker - Estimation of GFR using endogenous filtration
markers - urea
- creatinine
- Cystatin C
7GFR contd
- Estimating equations for GFR using serum
creatinine - Cockcroft-Gault Equation
- Ccr (140-Age) x weight( 0.85 if
female)/(72xPcr) - MDRD study equation
-
8Chronic 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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12Discussion
- History
- Duration of disease
- Cause of disease
- Manifestation of systemic disease
- Complications of CRF
-
13History
- Type of dialysis
- Frequency of dialysis
- Tolerance of dialysis
- Dry weight of the patient
14Physical Examination
- Mark Record the site of venous access for
Dialysis
15Cardiovascular 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
16CVD in CKD
- Hypertension
- Uremia
- Anemia
- Coronary valvular calcification
- Dyslipidemia
- Increased markers of inflammation
17CVD 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
18Assessment of Other Systems
- Respiratory
- Hematology
-
- Fluid Electrolyte
- Gastro intestinal
19Pre Operative Preparation
- Treat anemia
- Dialysis
- When to Dialyse
- How much fluid to be removed
- Effects of Dialysis
-
20Anesthesia planning
- GA Vs Regional
- Premedications
- Intraoperative Management
- Post operative pain fluid management
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24Anesthesia 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)
25Surgical 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)
26Pre-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
27Choice 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)
28Conduct of Anaesthesia
- Induction
- Rapid Sequence induction
- Propfol / Thiopentone / Ketamin
- Fentanyl (5mcg/kg) / Esmolol
- Atracurium /
- O2 N2O isoflurane
- ? Sevoflurane (Compound A controversy)
29Equipment / 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
30Fluid 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.
31Immunosuppression
- Methyl Prednisolon (500 mg. Solumedrol)
- IV Slowly (30-60 mins) before transplant.
- Cardiac Arrest
- Arrhythmias
- Circulatory Collapse
- Azathioprim
- Cyclosporin
32Post operative period
- Recovery
- ICU Stay Protocols Fluid / Urine output.
- Pain Relief PCA / Epidural
- Haemodialysis
- CXR
33Dual Kidney Transplant
- Two kidneys from aged donor are placed in to one
recipient. - Long duration of surgery / Otherwise no
difference in management.
34Thank you
www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
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