Chapter 27. Chronic Renal Failure

Gebhard Wagener, MD

|Download (.pdf)|Print

Organ Systems Involved in Renal Failure

Neuro

Uremic encephalopathy
Depends on rate of rise of BUN, not absolute value
Peripheral and autonomic neuropathy

Cardiac

Uremic pericarditis (rare)
Hypertension
Left ventricular hypertrophy and congestive heart failure (CHF)

Respiratory

Volume overload and pulmonary edema

Gastrointestinal

Delayed gastric emptying

Renal

Acidosis:
- Non-anion gap acidosis with renal bicarbonate loss and hyperchloremia
- Anion gap acidosis due to hyperphosphatemia
Hyperkalemia:
- Worsened by acute acidosis (pH ⇓ by 0.1 causes K+ ⇑ by 0.5 mEq/L)

Hematology

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

Others

Vascular access
Tunneled dialysis catheter
Double-lumen central venous catheters (Vas Cath)
Arteriovenous (AV) fistula and shunts

History

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?

Physical Exam

Examine shunt site and auscultate the shunt
Evaluate for signs of CHF and neuropathy
Examine abdomen in case of peritoneal dialysis

Tests

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.

Regional Anesthesia

Possible if no coagulopathy present
Document preexisting neuropathy
Sympathectomy may exacerbate autonomic dysfunction and hypotension

General Anesthesia

Positioning:
- Careful positioning of arms with attention to fistula
Induction:
- 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
Fluids:
- 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
- Drugs:
  - 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
- Extubation:
  - Check arterial blood gas prior to extubation for any longer cases

Get Free Access Through Your Institution

Learn how to see if your library subscribes to McGraw Hill Medical products.

Subscribe: Institutional or Individual

Sign In

Username

Password

Forgot Password? Forgot Username?

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.