Organ Systems Involved in Renal Failure
- Uremic encephalopathy
- Depends on rate of rise of BUN, not absolute value
- Peripheral and autonomic neuropathy
- Uremic pericarditis (rare)
- Left ventricular hypertrophy and congestive heart failure (CHF)
- Volume overload and pulmonary edema
- Non-anion gap acidosis with renal bicarbonate loss and hyperchloremia
- Anion gap acidosis due to hyperphosphatemia
- Worsened by acute acidosis (pH ⇓ by 0.1 causes K+ ⇑ by 0.5 mEq/L)
- Normocytic, normochromic anemia
- Uremic platelet dysfunction and coagulopathy:
- Impaired von Willebrand factor (vWF) release from endothelium ⇒ impaired platelet activation
- Can be treated with desmopressin (0.3 μg/kg) that releases endogenous vWF
- Immunosuppression due to myelodepression
- Catheter-related infections
- Peritonitis with peritoneal dialysis
- Vascular access
- Tunneled dialysis catheter
- Double-lumen central venous catheters (Vas Cath)
- Arteriovenous (AV) fistula and shunts
- How long has the patient been on dialysis?
- When was the last dialysis?
- How long was the last dialysis?
- Were there any problems during the last dialysis such as hypotension, impaired fluid removal, dizziness?
- Any recent fever, chills, or infections?
- In case of peritoneal dialysis: when was the abdomen filled or emptied the last time?
- Examine shunt site and auscultate the shunt
- Evaluate for signs of CHF and neuropathy
- Examine abdomen in case of peritoneal dialysis
- Complete blood count (anemia), serum chemistry (K+, BUN, Mg2+, phosphate), and coagulation profile
- ECG (cardiomyopathy, low voltage with uremic pericardial effusion)
- Chest x-ray (pulmonary edema and pleural effusions, catheter location, cardiomyopathy)
Schedule dialysis 1 day prior to surgery.
Schedule RBC transfusion during hemodialysis if necessary.
Continue peritoneal dialysis until surgery.
- Possible if no coagulopathy present
- Document preexisting neuropathy
- Sympathectomy may exacerbate autonomic dysfunction and hypotension
- Careful positioning of arms with attention to fistula
- Minimize sedative agents
- Rapid sequence induction if delayed gastric emptying is suspected
- Succhinylcholine may be used if preoperative K+ <5 mEq/L
- Avoid rocuronium or vecuronium; preferred NMB is cisatracurium
- Minimize fluids for minor surgery
- For major and intermediate surgery:
- Replace fluid loss (blood loss and insensitive losses) with lactated Ringer (LR) or other balanced salt solutions, not normal saline (NS)
- NS causes hyperchloremic acidosis that worsens hyperkalemia and may preclude extubation
- Normal metabolism (independent from renal function):
- (Cis-) atracurium, succinylcholine, esmolol, remifentanil
- Titrate all other drugs to effect:
- Vecuronium, rocuronium, fentanyl, midazolam, hydromorphone
- Avoid (or titrate carefully) drugs with renally eliminated metabolites:
- Morphine, vecuronium, meperidine, midazolam
- Sevoflurane is probably safe but avoid low fresh gas flow
- Check arterial blood gas prior to extubation for any longer cases...